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Daniels - 2009 - Complications of Obesity in Children and Adolescen
Daniels - 2009 - Complications of Obesity in Children and Adolescen
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REVIEW
Complications of obesity in children and adolescents
SR Daniels
Department of Pediatrics, University of Colorado School of Medicine, and The Children’s Hospital, Denver, CO, USA
The increasing prevalence and severity of obesity in children and adolescents has provided greater emphasis on the wide variety
of comorbid conditions and complications that can be experienced as a consequence of obesity. These complications can occur
both in the short term and in the long term. Some complications, earlier thought to be long-term issues, which would only
occur in adulthood, have now been shown to occur in children and adolescents. These findings have raised concerns about the
overall health experience of those who develop obesity early in life and have even raised questions about whether the obesity
epidemic might shorten the life span of the current generation of children. In this paper, I will examine current knowledge
regarding the different organ systems that may be impacted by childhood obesity.
International Journal of Obesity (2009) 33, S60–S65; doi:10.1038/ijo.2009.20
Keywords: mortality; CVD risk factors; insulin resistance; dyslipidemia; nonalcoholic fatty liver disease; sleep apnea
Skeletal
Tibia vara (Blount disease)
Slipped capital-femoral epiphysis Metabolic
Other
Polycystic ovary syndrome Obesity is associated with a wide array of metabolic
Pseudotumor cerebri complications in adults. These include insulin resistance,
dyslipidemia and type 2 diabetes mellitus. These metabolic
Comorbid conditions of childhood obesity are presented by organ systems.
complications have now also been found to be associated
with obesity in adolescents.
with familial hypercholesterolemia. They found that in these Steinberger et al.20 have shown that obesity during child-
high-risk individuals, coronary calcium can be present early hood is associated with decreased insulin sensitivity and
in life. They also found that in the presence of high low- increased circulating insulin levels. They have also shown
density lipoprotein cholesterol, a high body mass index that these abnormalities often persist into young adulthood.
(BMI) was an important factor in determining the presence Insulin resistance is an important factor in the development
of calcified coronary lesions. of type 2 diabetes. The period of growth and development
Obesity is quite important in the pathogenesis of hyper- during adolescence is associated with a normal increase in
tension. Although the mechanism of this relationship is not insulin resistance.21 If additional insulin resistance develops
completely understood, epidemiologic studies consistently related to obesity during this time, then it may lead first to
show a strong relationship between obesity and hyperten- glucose intolerance, and then to type 2 diabetes mellitus.
sion for both adults and children.11 Rosner et al.12 have The prevalence of type 2 diabetes has increased in adoles-
shown that the relative risk of hypertension associated cence and has been reported in children as young as 8 years
with overweight ranges from 2.5 to 3.7 in children and of age.22 Although the classification of type 1 and type 2
adolescents. diabetes is complex in obese adolescents, a review from the
Evaluation of national survey data has shown that there American Diabetes Association reports that as high a
has been a trend of increasing blood pressure that has proportion as 45% of newly diagnosed cases of diabetes in
paralleled the increase in the prevalence of obesity.13 children and adolescents are now type 2 diabetes in the era
Investigators of the Muscatine Study have shown that in of increased prevalence and severity of obesity in young
addition to the childhood level of blood pressure, the individuals.23
development of overweight in childhood is one of the Dyslipidemia may occur in children and adolescents as a
strongest predictors of the level of blood pressure in result of obesity. The most common abnormality of lipids
adulthood.14 More recently, Din-Dzietham et al.15 have and lipoproteins associated with obesity is an increase in
evaluated national survey data in the United States from triglycerides and a decrease in high-density lipoprotein
1963 to 2002 for 8- to 17-year-old children and adolescents. cholesterol. This has been called atherogenic dyslipidemia
They found that the prevalence of both pre-high blood because of its potential to accelerate atherosclerosis. Obesity
pressure and high blood pressure increased by 2.3 and 1%, can also contribute to an increase in low-density lipoprotein
respectively, between 1988 and 1999. This reversed an earlier cholesterol. However, it is unclear if this is a direct effect or
downward trend. This increase in the prevalence of high related to increased levels of saturated fat and cholesterol
blood pressure was at least partly explained by increased often present in the diet of overweight individuals during
obesity and in particular an increase in abdominal obesity. childhood. In the Muscatine Study, BMI and the change in
Obesity
Gastrointestinal
Pharyngeal and
A major concern is the development on nonalcoholic fatty submental fat Abdominal fat
liver disease (NAFLD). This disorder is characterized by the
accumulation of macrovesicular fat in hepatocytes. This Chest-wall fat
condition was first recognized in adults in the 1950s. The
first reports of NAFLD in children were in the 1980s.31 Upper airway Lung volume
NAFLD can be progressive. Patients can develop non- collapsability
alcoholic steatohepatitis (NASH) with an inflammatory
component that can then progress to hepatic fibrosis and
Obstructive
ultimately cirrhosis. Adult patients have even required liver sleep apnea
transplantation as a result of the progression of NAFLD.
Children with NAFLD are usually asymptomatic. Hepato-
Hypoxemia
megaly is reported to be present in 40–50% of children with
NAFLD; however, this may be difficult to discern on physical
examination of an obese child or adolescent.32 Cardiovascular
The pathophysiology of NAFLD and NASH is not com- abnormality
pletely understood. Clinical studies suggest that insulin Figure 1 Relationship of obesity to obstructive sleep apnea and cardiovas-
resistance may play an important role.32 Children with type cular disease.