DOI:10.2214/AJR.06.0651
AJR 2007; 188:1118-1130
© American Roentgen Ray Society
Diseases Associated with Childhood Obesity
Arabinda K. Choudhary1,
Lane F. Donnelly,
Judy M. Racadio and
Janet L. Strife
1 All authors: Department of Radiology, Cincinnati Children's Hospital Medical
Center, University of Cincinnati Medical Center, 3333 Burnet Ave., Cincinnati,
OH 45229-3030.
Received May 15, 2006;
accepted after revision December 6, 2006.
Address correspondence to J. L. Strife
(janet.strife{at}cchmc.org).
CME This article is available for CME credit. See
www.arrs.org
for more information.
FOR YOUR INFORMATION
This article is available for CME credit. See
www.arrs.org
for more information.
Abstract
OBJECTIVE. Radiologists can play an active role in children's health
by increasing awareness of diseases associated with obesity. This article
reviews key imaging findings in obesity-related diseases, current issues in
imaging obese children, and treatment strategies.
CONCLUSION. There has been a well-documented pediatric obesity
epidemic and a dramatic increase in clinical diseases associated with it.
These serious health consequences affect nearly every organ system. Despite
the increasing prevalence of obesity and the associated health hazards,
pediatric obesity as a diagnosis is often overlooked by health care
providers.
Keywords: obesity • pediatric radiology • practice of radiology
Introduction
Obesity is a major threat to children's health today. The prevalence
of obesity has been steadily increasing; over the past 25 years, the number of
obese children has nearly tripled
[1-3].
By body mass index (BMI) criteria (
95th percentile for age and sex),
approximately 15% of children 6-19 years old are obese
[4].
Longitudinal studies now show that 60% of children who are overweight
during preschool years are overweight at the age of 12 years
[2]. Data regarding trends show
that children who are overweight anytime during childhood are more likely to
continue to gain weight and to reach overweight status by adolescence.
Multiple other studies have shown that overweight during adolescence is a good
predictor of overweight in adulthood. Some have claimed that pediatric obesity
has emerged as a new chronic disease
[5].
Obesity is a disease that can lead to myriad comorbid conditions. It has
been shown to substantially increase years of life lost
[6], mortality
[7], and health care costs
[8,
9]. An American Academy of
Pediatrics policy statement described the significant health and financial
burdens of pediatric obesity and the need for strong and comprehensive
prevention efforts [4].
However, despite the gravity of the disease and its rising prevalence, primary
care givers do not consistently diagnose obesity in children and miss
significant opportunities for intervention
[10,
11]. In addition, pediatric
radiologists usually do not include obesity as a diagnosis on imaging reports
[12].
Childhood is a critical time for physicians to act as child advocates by
attempting to prevent, identify, and treat obesity before these obese children
become obese adults and the associated morbidity worsens. The serious
complications associated with obesity occur in nearly every organ system.
The purpose of this article is to increase awareness among radiologists of
the diseases associated with pediatric obesity and of the need to use the
radiology report to note obesity or large body habitus in order to increase
awareness of referring physicians. Another way to emphasize the radiographic
finding is to state that likely the specific condition is associated with
pediatric obesity. When clinicians treat the comorbid disease such as
hypertension or gallstones and do not address the underlying disease of
obesity, an opportunity to prevent other comorbid diseases is lost.
Diseases Associated with Childhood Obesity Metabolic Syndrome
Pediatric metabolic syndrome is a group of risk factors in one person that
includes obesity, insulin resistance, hypertension, and other metabolic
abnormalities; it is present in nearly half of all severely obese children and
it worsens with increasing body mass index or insulin resistance
[13]. Children have abnormal
results of glucose tolerance tests, high triglycerides, and low HDL
(high-density lipoprotein) cholesterol concentrations
[13].
Childhood obesity has been accompanied by an increase in the prevalence of
type 2 diabetes [14]. Children
with obesity-related diabetes face a much higher risk of many comorbid
diseases, especially kidney failure
[15], by middle age and death
from cardiovascular events, when compared with adult onset of diabetes
[16].
Cardiac Disorders
As the prevalence of pediatric obesity increases, so does pediatric primary
hypertension [17,
18]. Obese children have an
approximately threefold higher risk for hypertension than nonobese children
[19]. Obese children with
hypertension also frequently have other components of the metabolic syndrome,
including dyslipidemia, insulin resistance, and hyperinsulinemia
[20].
The metabolic syndrome is well recognized as posing a major risk for
cardiovascular disease in adults; however, substantial evidence now indicates
that this syndrome begins in childhood, and therefore significant
cardiovascular risk begins in childhood
[20]. In addition, obese
hypertensive patients often develop left ventricular hypertrophy (LVH), which
also increases the risk of cardiovascular morbidity and mortality
[21] (Fig.
1A,
1B).
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Fig. 1A —Left ventricular hypertrophy (LVH), echocardiographic views in
16-year-old girl. Parasternal short-axis sonogram shows no evidence of LVH.
Arrows indicate normal-sized left ventricular wall.
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Fig. 1B —Left ventricular hypertrophy (LVH), echocardiographic views in
16-year-old girl. Parasternal short-axis sonogram shows LVH in 314-lb (142-kg)
adolescent girl with markedly thickened left ventricular wall
(arrows).
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The fundamental impact of weight control on the risk of disease and
longevity is now well established. A recent analysis concluded that obesity
has a detrimental effect on longevity and that the steady rise in life
expectancy during the past two centuries may soon come to an end
[22].
Respiratory Disorders
Obstructive sleep apnea syndrome (OSAS) is a significant problem in
children and has adverse consequences for growth and development
[23]; it often results in
neurocognitive deficits [23].
OSAS is characterized by recurrent episodes of partial or complete obstruction
of the upper airway during sleep, which disrupt the normal ventilation and
sleep patterns [23]. Obese
children are more apt to have persistent OSA after tonsillectomy and
adenoidectomy than are nonobese children
[24] (Fig.
2A,
2B). It is not clear whether
the mechanism of OSA is related to increased visceral fat having an effect on
decreasing airway tone and predisposing the airways to collapse, or whether
increased fat in the neck decreases the caliber of the airway. Cine MRI sleep
studies can be used to evaluate both static anatomy abnormality and dynamic
abnormalities that lead to functional collapse of the airway in these children
[25] (Fig.
3A,
3B,
3C,
3D).
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Fig. 3C —Airway obstruction in 18-year-old boy. Sagittal T1-weighted image
reveals excessive soft tissue and enlargement of adenoids (A). Arrow indicates
open airways. P = palatine tonsil, T = tongue.
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Gastrointestinal Disorders
Nonalcoholic fatty liver disease is associated with obesity and insulin
resistance [25]. As the
prevalence of obesity and insulin resistance in children has been increasing
dramatically, so has pediatric nonalcoholic fatty liver disease
[26,
27], which is now probably the
most common form of chronic liver disease in children
[28]. Nonalcoholic fatty liver
disease is characterized by an abnormal accumulation of fat in the liver. It
is usually asymptomatic and is often found incidentally when hepatic steatosis
is documented on abdominal imaging
[27]. It may be associated
with moderate elevations in levels of serum aminotransferases, triglycerides,
and cholesterol. Although hepatic steatosis alone has a good prognosis
[26], as fibrosis develops
there is an increased likelihood of progression to nonalcoholic
steatohepatitis, cirrhosis, and end-stage liver disease, even in children
[26-28].
Nonalcoholic fatty liver disease may be detected on both sonography and
contrast-enhanced helical CT (Fig.
4A,
4B). Nonalcoholic
steatohepatitis is usually diagnosed at biopsy (Fig.
5A,
5B).
The presence of moderate to severe ( 30%) steatosis is a
contraindication for being a living donor; it also increases the risk of
postoperative complications for the donor after resection
[29]. Unenhanced CT with a
multivoxel study of attenuation values in multiple segments excels in the
qualitative diagnosis of steatosis of 30% or greater and would serve as a
useful tool in screening potential liver donors
[30,
31].
Obesity is well recognized as a risk factor for the development of
cholesterol gallstones in adults and children
[32,
33]. Cholesterol stones are
the most common type of gallstone. When bile is supersaturated with
cholesterol, it can crystallize and form a nidus for stone formation (Fig.
6A,
6B). Dietary factors such as
consumption of simple sugars and saturated fat have also been associated with
a higher risk of cholesterol gallstone formation
[32].
Gynecologic Disorders
Another complication of pediatric obesity and associated insulin resistance
is polycystic ovary syndrome (PCOS). Like pediatric hypertension and
nonalcoholic fatty liver disease, pediatric PCOS is increasing in prevalence
with the rise in obesity in children
[34]. In addition to
polycystic ovaries (Fig. 7A,
7B), PCOS is associated with
hyperandrogenism and associated symptoms (irregular menses, hirsutism, and
acne) [34,
35].
Pediatric obesity has also been associated with premature adrenarche or the
increase in adrenal androgen production. Evidence exists that prepubertal
increases in adrenal androgens in the presence of obesity may be associated
with earlier onset of sexual maturity
[36,
37]. Premature adrenarche can
also lead to a transient acceleration of growth and bone maturation
[36-38].
Therefore, accelerated maturation may be noted on skeletal radiography of
obese children (Fig. 8).
Musculoskeletal Disorders
Slipped capital femoral epiphysis (SCFE) is a hip disorder in adolescents
that causes symptoms of hip or knee pain. It occurs when the femoral head
slips off the femoral neck along a weakened growth plate. SCFE is more likely
to occur in boys and in overweight patients (Fig.
9A,
9B). In addition, the
possibility exists that SCFE occurs in younger children in the presence of
obesity, and that early age of onset and obesity increase the risk for
bilateral disease (Strife JL, unpublished data).
Adolescent tibia vara (Blount disease) is also related to obesity
[39,
40]. Obesity predisposes to
repetitive trauma, with abnormal force being directed on the medial tibial
growth plate, which results in growth plate suppression
[39]. This leads to decreased
growth and a varus deformity. Both metaphyseal-diaphyseal and anatomic
tibiofemoral angle measurements show greater malalignment in overweight
patients [41]. Early
degenerative arthritis of the knee may result. MRI shows features of failure
of enchondral ossification of the medial growth plate, unossified medial
epiphysis, edema of the medial epiphysis, varus deformity, and hypertrophy of
the medial meniscus [42] (Fig.
10A,
10B,
10C).
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Fig. 10A —Blount disease (tibia vara) in two girls. In 11-year-old obese girl,
radiograph with patient standing shows loss of height of medial tibial
epiphysis and slanting (tibia vara) (arrow).
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Fig. 10B —Blount disease (tibia vara) in two girls. In 4-year-old obese girl,
coronal T1-weighted MR image (B) shows irregular, widening depression
of medial growth plate; unossified medial epiphysis (arrow); and
hypertrophy of medial meniscus. Coronal T2-weighted fast spin-echo image
(C) illustrates edema of medial epiphysis and irregularity of growth
plate cartilage (arrow) that extends medially and inferiorly.
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Fig. 10C —Blount disease (tibia vara) in two girls. In 4-year-old obese girl,
coronal T1-weighted MR image (B) shows irregular, widening depression
of medial growth plate; unossified medial epiphysis (arrow); and
hypertrophy of medial meniscus. Coronal T2-weighted fast spin-echo image
(C) illustrates edema of medial epiphysis and irregularity of growth
plate cartilage (arrow) that extends medially and inferiorly.
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Children and adolescents who are overweight are more likely than their
normal-weight counterparts to have fractures
[42]. Dual-energy X-ray
absorptiometry (DXA) shows that overweight children have a greater bone
density, but it does not protect them from fractures. The cause is
speculative, but it has been suggested that the overweight boy is likely to
fall with a greater force than a nonoverweight boy and more likely to suffer a
fracture.
Finally, it is well recognized that the abnormal mechanical joint loading
that occurs in obesity is a primary cause of osteoarthritis
[43], which has been
documented as occurring in obese adolescents
[44]
(Fig. 11).
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Fig. 11 —Osteoarthritis of knee joint in 16-year-old girl with chronic knee
pain. Anteroposterior radiograph of knee joint shows obesity, loss of height
of medial component, and small osteophyte (arrow).
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Neurologic Disorders
Idiopathic intracranial hypertension (pseudotumor cerebri) is a condition
characterized by increased intracranial pressure with no evidence of a
specific cause, such as a space-occupying lesion
[45]. Idiopathic intracranial
hypertension occurs with significantly greater frequency in obese children and
adults [45,
46] (Fig.
12A,
12B,
12C).
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Fig. 12A —Pseudotumor cerebri in 19-year-old girl who presented with visual
loss and papilledema on ophthalmologic examination. T2-weighted axial
(A) and coronal (B) MR images show increased fluid in optic
sheath (arrows) surrounding optic nerve. Brain was otherwise normal,
and no dural sinus thrombosis was seen.
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Fig. 12B —Pseudotumor cerebri in 19-year-old girl who presented with visual
loss and papilledema on ophthalmologic examination. T2-weighted axial
(A) and coronal (B) MR images show increased fluid in optic
sheath (arrows) surrounding optic nerve. Brain was otherwise normal,
and no dural sinus thrombosis was seen.
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Fig. 12C —Pseudotumor cerebri in 19-year-old girl who presented with visual
loss and papilledema on ophthalmologic examination. Because of obesity,
interventional imaging was used for lumbar puncture. Arrow indicates needle
tip.
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Vascular Disorders
Obesity is well recognized in adults to be a risk factor for venous
thromboembolic disease [47,
48]. Although the same
association has not yet been shown in children, it is reasonable to believe
that obesity may pose an increased risk for the development of deep venous
thrombosis and subsequent pulmonary embolism in children as well (Figs.
13A,
13B and
14A,
14B). Obesity has also been
shown to be independently associated with abnormal arterial function and
structure, with an increased intimal-medial thickness in otherwise healthy
young children [49].
Intimal-medial thickness is a noninvasive marker for early atherosclerotic
changes and is related to the cardiovascular risk factors of obesity,
especially hypertension, chronic inflammation, and impaired glucose metabolism
[50].
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Fig. 13A —Deep venous thrombosis in 15-year-old obese girl. Longitudinal
sonogram using 4-MHZ probe shows clot (solid arrow) in proximal
femoral vein. Normal flow is seen in patent left proximal femoral artery
(dashed arrow).
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Fig. 13B —Deep venous thrombosis in 15-year-old obese girl. Transverse
sonograms without (right) and with (left) compression show
occluding clot and noncompressible vein (arrows). Femoral artery (A)
is adjacent to vein (V).
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Fig. 14B —Pulmonary artery embolism in 14-year-old obese boy who presented
with chest pain. Axial CT scan of pelvis shows dilatation of right iliac vein
and occlusive clot (solid arrow). Dotted arrow shows normal left
iliac vein. Note soft-tissue obesity.
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Causes of Pediatric Obesity
What are the causes of the pediatric obesity epidemic? The answers are
complex and multifactorial, but the epidemic has been recognized in other
countries. Pediatric obesity has been associated with a sedentary lifestyle;
increased television viewing; an increase in computer games; lack of physical
activity; and dietary causes including increased fat content of food, large
proportions, and high-calorie drinks. Pediatric obesity is also affected by
sex, ethnicity, culture, and hereditary factors.
One of the most striking findings is that a child who is overweight at 2
years has a greater than 50% chance of being overweight by adolescence, a
tendency that will continue into adulthood. Significant research is being
funded that is directed to seeking associations and causes. More recently, it
has been suggested that prenatal characteristics, including race, ethnicity,
maternal smoking during pregnancy, and maternal prepregnancy obesity, exert an
influence on the child's weight status through an early tendency toward
overweight that is then perpetuated as the child ages. Overweight prevention
may need to begin before pregnancy or in early childhood
[1,
51].
Treatment of Pediatric Obesity
Treating pediatric obesity is now recognized as a significant health care
issue. Minimal approaches promote healthy eating and lifestyle changes and
advocate an increase in physical activity. However, selected interventional
treatment through decreased caloric intake and increased physical activity has
been minimally effective in achieving sustained weight loss in the markedly
obese. Specific management also includes referring to specialists, dieticians,
screening laboratories, and endocrinologists, and referring for preventive
cardiology. Surgical weight loss has been advocated as the only treatment
shown to achieve durable weight loss in the obese patient. Bariatric surgery
has increased substantially among pediatric adolescents. Surgical treatment of
pediatric obesity allows resolution of associated comorbidities and improved
quality of life [52,
53].
Some have advocated an antiobesity campaign focusing on creating new social
policies that encourage weight loss, such as adjustments in insurance
premiums; compulsory exercise for students from elementary schools through
college; health food choices in cafeterias; and an educational campaign to
enable children, adolescents, and adults to make informed choices. The U.S.
population has already shown the ability to shift to a healthier lifestyle.
The examples cited include the national initiatives to reduce morbidity and
mortality associated with motor vehicle accidents through the use of mandated
seat belts, to reduce the spread of AIDS through the prevention of disease,
and to reduce the incidence of lung cancer through an increased awareness of
the consequences of smoking cigarettes.
Some evidence exists as to the effectiveness of population-based
interventions, the potential benefits of increased awareness, and possibly the
benefits of routine screening
[2]. Nevertheless, good
evidence shows that maintaining a normal weight is a positive health goal, and
efforts to reduce overweight should begin in childhood.
Obesity Imaging
Several difficulties may be encountered during imaging of obese patients.
Larger radiation exposures occur in obese patients because higher doses are
necessary to penetrate increased soft tissues. Image quality can be
compromised, resulting in nondiagnostic examinations in very large patients
(Fig. 15A,
15B). This occurs during
radiography, fluoroscopy, sonography, CT, and MRI. Obesity can also compromise
the quality of an examination because of the patient's inability to move and
cooperate with proper positioning for radiologic imaging and procedures.
Finally, obese patients may exceed the weight and size limitations for
standard imaging equipment, including CT, MRI, fluoroscopy, and interventional
radiology equipment [54].
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Fig. 15B —Technical challenges in imaging obese patients. Axial CT scan in
11-year-old boy was obtained because of trauma and shows poor resolution of
bones despite adjustment of exposure factors.
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Conclusion
Although the prevalence of childhood obesity has reached epidemic
proportions, it is underrecognized and undertreated by pediatric primary care
providers [5]. Preventing,
recognizing, and treating obesity are some of the most challenging dilemmas
facing pediatrics [55]. A
recent study in an outpatient pediatric academic center showed that in
children who meet the criteria for obesity, providers of care document obesity
in their clinical assessments in only 53%
[5]. Our study highlights the
need for increased awareness and identification of obesity and the potential
contributing role of the radiologist. If a problem is not recognized, it
cannot be treated.
Finding effective strategies to treat obesity through the timely
identification of its presence by health care providers is a crucial step in
recognizing the disease and in its potential management. Despite the fact that
the radiologists are aware of the clinically associated diseases, they rarely
mention these associations in their reports. In so doing, radiologists miss
their opportunity to be advocates and to identify children at risk of serious
health consequences.
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Abstract
Introduction
