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Calcaterra V, Cena H, Garella V, Loperfido F, Chillemi C, Manuelli M, Mannarino S, Zuccotti G. Assessment of Epicardial Fat in Children: Its Role as a Cardiovascular Risk Factor and How It Is Influenced by Lifestyle Habits. Nutrients 2024; 16:420. [PMID: 38337703 PMCID: PMC10857556 DOI: 10.3390/nu16030420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 01/26/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024] Open
Abstract
Epicardial adipose tissue (EAT) stands out as a distinctive repository of visceral fat, positioned in close anatomical and functional proximity to the heart. EAT has emerged as a distinctive reservoir of visceral fat, intricately interlinked with cardiovascular health, particularly within the domain of cardiovascular diseases (CVDs). The aim of our overview is to highlight the role of EAT as a marker for cardiovascular risk in children. We also explore the influence of unhealthy lifestyle habits as predisposing factors for the deposition of EAT. The literature data accentuate the consequential impact of lifestyle choices on EAT dynamics, with sedentary behavior and unwholesome dietary practices being contributory to a heightened cardiovascular risk. Lifestyle interventions with a multidisciplinary approach are therefore pivotal, involving a nutritionally balanced diet rich in polyunsaturated and monounsaturated fatty acids, regular engagement in aerobic exercise, and psychosocial support to effectively mitigate cardiovascular risks in children. Specific interventions, such as high-intensity intermittent training and circuit training, reveal favorable outcomes in diminishing the EAT volume and enhancing cardiometabolic health. Future clinical studies focusing on EAT in children are crucial for advancing our understanding and developing targeted strategies for cardiovascular risk management in this population.
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Affiliation(s)
- Valeria Calcaterra
- Pediatric and Adolescent Unit, Department of Internal Medicine, University of Pavia, 27100 Pavia, Italy
- Pediatric Department, Buzzi Children’s Hospital, 20154 Milan, Italy;
| | - Hellas Cena
- Laboratory of Dietetics and Clinical Nutrition, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy; (H.C.); (F.L.)
- Clinical Nutrition and Dietetics Service, Unit of Internal Medicine and Endocrinology, Istituti Clinici Scientifici Maugeri IRCCS, 27100 Pavia, Italy;
| | - Vittoria Garella
- Pediatric Cardiology Unit, “V. Buzzi” Children’s Hospital, 20154 Milan, Italy; (V.G.); (C.C.); (S.M.)
| | - Federica Loperfido
- Laboratory of Dietetics and Clinical Nutrition, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy; (H.C.); (F.L.)
| | - Claudia Chillemi
- Pediatric Cardiology Unit, “V. Buzzi” Children’s Hospital, 20154 Milan, Italy; (V.G.); (C.C.); (S.M.)
| | - Matteo Manuelli
- Clinical Nutrition and Dietetics Service, Unit of Internal Medicine and Endocrinology, Istituti Clinici Scientifici Maugeri IRCCS, 27100 Pavia, Italy;
| | - Savina Mannarino
- Pediatric Cardiology Unit, “V. Buzzi” Children’s Hospital, 20154 Milan, Italy; (V.G.); (C.C.); (S.M.)
| | - Gianvincenzo Zuccotti
- Pediatric Department, Buzzi Children’s Hospital, 20154 Milan, Italy;
- Department of Biomedical and Clinical Science “L. Sacco”, University of Milan, 20157 Milan, Italy
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Muñoz-Hernando J, Escribano J, Ferré N, Closa-Monasterolo R, Grote V, Koletzko B, Gruszfeld D, ReDionigi A, Verduci E, Xhonneux A, Luque V. Usefulness of the waist-to-height ratio for predicting cardiometabolic risk in children and its suggested boundary values. Clin Nutr 2021; 41:508-516. [PMID: 35016145 DOI: 10.1016/j.clnu.2021.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 10/20/2021] [Accepted: 12/04/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND & AIMS Only limited information is available on the usefulness of the waist-to-height ratio (WHtR) as an abdominal obesity marker in children. Our aim was to compare the ability of a WHtR >90th percentile, a WHtR ≥0.50, a WHtR ≥0.55 and a BMI z-score ≥2 SD to predict cardiometabolic risk in children followed-up at different ages. METHODS We evaluated data from 660 children at 5, 8 and 11 years of age who participated in the Childhood Obesity Project trial in 5 European countries. We classified children with or without cardiometabolic (CMet) risk (yes vs. no) according to the presence of ≥2 parameters (blood pressure, HOMA-IR, triglyceride levels and high-density lipoprotein (HDL) cholesterol levels) ≥90th percentile. RESULTS The odds ratio for CMet risk in children at all followed-up ages was statistically significant for all measures. The OR for the WHtR≥0.55 cut-off was 29.1 (5.6, 151.7) at 5 years of age, 11.8 (4.1, 33.8) at 8 year of age and 3.6 (1.7, 7.7) at 11 years of age, compared to the WHtR<0.55 cut-off. The WHtR≥0.55 cut-off showed a higher OR at younger ages than the BMI z-score ≥2SD, WHtR ≥90th percentile and WHtR≥0.50 cut-offs and a higher positive predictive value (82% at 5 years of age compared to 55%, 36% and 41%, respectively). CONCLUSION A WHtR≥0.55 is a suitable cut-off for screening children at high cardiometabolic risk in the general young European population.
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Affiliation(s)
- Judit Muñoz-Hernando
- Paediatrics, Nutrition and Development Research Unit, Universitat Rovira i Virgili, IISPV, 43201, Reus, Spain.
| | - Joaquin Escribano
- Paediatrics, Nutrition and Development Research Unit, Universitat Rovira i Virgili, IISPV, 43201, Reus, Spain.
| | - Natalia Ferré
- Paediatrics, Nutrition and Development Research Unit, Universitat Rovira i Virgili, IISPV, 43201, Reus, Spain
| | - Ricardo Closa-Monasterolo
- Paediatrics, Nutrition and Development Research Unit, Universitat Rovira i Virgili, IISPV, 43201, Reus, Spain
| | - Veit Grote
- Dept. Paediatrics, Dr von Hauner Children's Hospital, University Hospital, LMU - Ludwig-Maximilians-Universität, 80337, Munich, Germany
| | - Berthold Koletzko
- Dept. Paediatrics, Dr von Hauner Children's Hospital, University Hospital, LMU - Ludwig-Maximilians-Universität, 80337, Munich, Germany; Else-Kröner-Seniorprofessor of Paediatrics, LMU Ludwig-Maximilians-Universität, 80337, Munich, Germany.
| | - Dariusz Gruszfeld
- Neonatal Department, Children's Memorial Health Institute, 04-730, Warsaw, Poland.
| | - Alice ReDionigi
- Department of Health Sciences, University of Milan, 20146, Milan, Italy.
| | - Elvira Verduci
- Department of Health Sciences, University of Milan, 20146, Milan, Italy.
| | | | - Veronica Luque
- Paediatrics, Nutrition and Development Research Unit, Universitat Rovira i Virgili, IISPV, 43201, Reus, Spain; Serra Hunter Fellow, Universitat Rovira i Virgili, 43201, Reus, Spain.
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Calcaterra V, Cena H, Manuelli M, Sacchi L, Girgenti V, Larizza C, Pelizzo G. Body hydration assessment using bioelectrical impedance vector analysis in neurologically impaired children. Eur J Clin Nutr 2019; 73:1649-1652. [PMID: 30651604 DOI: 10.1038/s41430-018-0384-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 11/28/2018] [Accepted: 12/13/2018] [Indexed: 01/26/2023]
Abstract
Dehydration is common and frequently under-diagnosed in chronic malnourished children, leading to life-threatening conditions. In this pilot study we applied bioimpedance vector analysis (BIVA) to determine hydration status in 52 neurologically impaired (NI) paediatric patients (14.08 ± 5.32). Clinical and biochemical data were used to define malnutrition and dehydration. Body composition analysis and hydration were also assessed by BIVA and we considered 143 normal-weight healthy subjects (15.0 ± 1.7), as controls for hydration status assessment. BIVA revealed a pathological hydration status in NI children, showing higher resistance (p < 0.001) and reactance values (p = 0.001) compared to controls. No differences in reactance and resistance were detected between well-nourished and under-nourished subjects. Four patients out of 52 showed mild signs of dehydration; no severe dehydration was detected. Laboratory data, suggestive for dehydration, were similar in well-nourished and under-nourished NI subjects. In conclusion, in our sample of NI paediatrics, dehydration according to clinical signs and laboratory data was under-diagnosed. BIVA showed specific bioelectrical characteristics that could be compatible with impaired hydration status. Further studies are necessary to confirm that BIVA may an applicable tool for defining dehydration status and guiding rehydration in NI children.
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Affiliation(s)
- Valeria Calcaterra
- Paediatric Unit, Department of Internal Medicine, University of Pavia and Department of Maternal and Children's Health, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Hellas Cena
- Department of Public Health, Neurosciences, Experimental and Forensic Medicine, Section of Human Nutrition, University of Pavia, Pavia, Italy.,Clinical Nutrition and Dietetics Service, Unit of Internal Medicine and Endocrinology, ICS Maugeri IRCCS, Pavia, Italy
| | - Matteo Manuelli
- Department of Public Health, Neurosciences, Experimental and Forensic Medicine, Section of Human Nutrition, University of Pavia, Pavia, Italy
| | - Lucia Sacchi
- Department of Electrical, Computer and Biomedical Engineering of the University of Pavia, Pavia, Italy
| | - Vincenza Girgenti
- Paediatric Surgery Department, Children's Hospital "G. Di Cristina", ARNAS Civico-di Cristina-Benfratelli", Palermo, Italy
| | - Cristiana Larizza
- Department of Electrical, Computer and Biomedical Engineering of the University of Pavia, Pavia, Italy
| | - Gloria Pelizzo
- Paediatric Surgery Department, Children's Hospital "G. Di Cristina", ARNAS Civico-di Cristina-Benfratelli", Palermo, Italy.
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Manuelli M, Blundell JE, Biino G, Cena H. Body composition and resting energy expenditure in women with anorexia nervosa: Is hyperactivity a protecting factor? Clin Nutr ESPEN 2018; 29:160-164. [PMID: 30661682 DOI: 10.1016/j.clnesp.2018.10.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 10/25/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND In subjects with anorexia nervosa (AN) physical exercise may cause or even prevent weight loss, body composition alterations and adaptive thermogenesis. To investigate the influence of behavioral patterns on body composition and energy expenditure in women with AN, we conducted a retrospective analysis in 62 patients with AN referring to our outpatients' clinic. MATERIALS AND METHODS We assessed anthropometric measurement of weight, height, and BMI; body composition was assessed by bioelectrical impedance analysis; resting energy expenditure was measured through indirect calorimetry. Patients' characteristics were assessed at the time of first evaluation. RESULTS The subjects were both restricting type (ANR, n = 39) and binge-eating/purging type (ANBP, n = 23) according to DSM-5. We observed a lower reactance (58.63 (11.9) vs. 66.5 (15.5) Ohm, p < 0.05) and higher total body water in ANR subjects. No differences were found in phase angle, fat mass or fat-free mass, nor in REE measures. Within ANR subgroup, we identified two behavioral patterns, with or without physical hyperactivity. Compared to dieting and fasting subjects, hyperactive subjects showed higher phase angle [5.6 (0.7) vs. 4.8 (0.8), p < 0.05], lower fat-free mass [82.5 (6.8) vs. 89.9 (7.5)%, p < 0.05], greater proportion of fat mass [17.5 (6.8) vs. 10.1 (7.5)%, p < 0.05] and body cell mass [46.6 (5.1) vs. 42.5 (5.5)%, p < 0.05]. Finally, hyperactive subjects had greater BMI than dieting or fasting subjects [18.2 (1.7) vs. 15.8 (1.7), p < 0.005]. CONCLUSION With limitations due to the small sample size, hyperactive subjects show body composition and energy metabolism features that seem protective in terms of prognosis.
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Affiliation(s)
- Matteo Manuelli
- Department of Public Health, Experimental and Forensic Medicine, Unit of Human Nutrition, University of Pavia, Via Bassi 21, 27100, Pavia, Italy.
| | - John E Blundell
- School of Psycology, University of Leeds, Leeds, LS2 9JT, UK
| | - Ginevra Biino
- Institute of Molecular Genetics, National Research Council of Italy, Pavia, Italy
| | - Hellas Cena
- Department of Public Health, Experimental and Forensic Medicine, Unit of Human Nutrition, University of Pavia, Via Bassi 21, 27100, Pavia, Italy
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Calcaterra V, Cena H, de Silvestri A, Albertini R, De Amici M, Valenza M, Pelizzo G. Stress Measured by Allostatic Load in Neurologically Impaired Children: The Importance of Nutritional Status. Horm Res Paediatr 2018; 88:224-230. [PMID: 28693012 DOI: 10.1159/000477906] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 05/30/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Allostatic load (AL) is the cumulative physiological wear and tear that results from repeated efforts to adapt to stressors over time. The life stress response is modified by nutritional status. AIM We estimated AL scores among neurologically impaired (NI) children; the association with malnutrition was also evaluated. METHODS Forty-one patients with severe disabilities were included. Data based on 15 biomarkers were used to create the AL score. A dichotomous outcome of high AL was defined for those who had ≥6 dysregulated components. Body mass index (BMI)-standard deviation score (SDS) <-2 or SDS ≥2 and biochemical markers (≥4) defined malnutrition. RESULTS High AL was noted in 17/41 of the whole sample (41.47%). Malnutrition occurred in 36.6% of the subjects. A significant correlation between high AL and malnutrition was observed (p = 0.01; ar ea under the receiver operating characteristic curve, 0.7457). High AL subjects had a significantly higher BMI (p = 0.009) and lower BMI-SDS (p = 0.003) than low AL subjects. AL score correlated with fat mass (p ≤ 0.01) and negatively correlated with fat-free mass (p ≤ 0.02). CONCLUSION In NI children, high AL was associated with malnutrition. Body composition is a better indicator than BMI of allostatic adjustments. AL estimation should be considered a measure of health risk and be used to promote quality of life in at-risk disabled populations.
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Affiliation(s)
- Valeria Calcaterra
- Department of the Mother and Child Health, Pediatric Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,Department of Internal Medicine, University of Pavia, Pavia, Italy
| | - Hellas Cena
- Department of Public Health, Experimental and Forensic Medicine, Unit of Human Nutrition, University of Pavia, Pavia, Italy
| | - Annalisa de Silvestri
- Biometry and Clinical Epidemiology, Scientific Direction, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Riccardo Albertini
- Laboratory of Clinical Chemistry, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Mara De Amici
- Immuno-Allergy Laboratory, Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Mario Valenza
- Operating Room Coordination, Ospedale ARNAS Civico, Di Cristina e Benfratelli, Palermo, Italy
| | - Gloria Pelizzo
- Pediatric Surgery Unit, Children's Hospital, Istituto Mediterraneo di Eccellenza Pediatrica, Palermo, Italy
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Calcaterra V, Cena H, Casali P, Iacobellis G, Albertini R, De Amici M, de Silvestri A, Comparato C, Pelizzo G. Epicardial Fat Thickness in Non-Obese Neurologically Impaired Children: Association with Unfavorable Cardiometabolic Risk Profile. ANNALS OF NUTRITION AND METABOLISM 2018; 72:96-103. [DOI: 10.1159/000484326] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 10/11/2017] [Indexed: 12/21/2022]
Abstract
Background: Cardiovascular risk is reported in disabled children and epicardial fat (EF) is considered an independent predictor of cardiovascular disease (CVD). No data on the EF thickness (EFT) evaluation in disabled children have been published. Objective: We investigated EFT in neurologically impaired (NI) children; its relationship with their metabolic profile was also considered. Methods: Clinical data, body composition estimation, biochemical profile, and ultrasound-measured EFT were performed in 32 disabled patients (12.4 ± 6.3 years). Pathological parameters were defined using the following criteria: waist circumference >95th percentile, waist to height ratio (WHtR) >0.5, total cholesterol and triglycerides (TG) values >95th percentile, high density lipoprotein cholesterol <5th percentile, fasting blood glucose >100 mg/dL, homeostasis model assessment for insulin resistance (HOMA) >97.5th percentile, and EFT >3.6 mm. Results: EFT values in NI children were higher compared with control group values (p = 0.02). EFT correlated with gender (p < 0.001), age (p = 0.02), pubertal stage (p = 0.04), as well as WHtR (p = 0.03). A correlation between EFT and leptin was also noted (p = 0.04). EFT levels significantly correlated with pathological TG (p = 0.01) and HOMA-IR (p = 0.04). Conclusions: Higher EFT was observed in NI children compared with controls. EFT values correlated with clinical, metabolic, and endocrinological parameters. Ultrasound-measured EFT could be used to promptly detect subclinical CVD and to prevent adverse outcomes in disabled children.
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Cena H, Stanford FC, Ochner L, Fonte ML, Biino G, De Giuseppe R, Taveras E, Misra M. Association of a history of childhood-onset obesity and dieting with eating disorders. Eat Disord 2017; 25:216-229. [PMID: 28139175 PMCID: PMC6261338 DOI: 10.1080/10640266.2017.1279905] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
This was a retrospective, observational chart review conducted on a convenience sample of 537 outpatients, aged 16-60 years, referred to an Italian Dietetic and Nutrition University Center. The study aimed to look at the association between a history of childhood obesity and dieting behaviors with development of eating disorders (EDs) at a later age. Subjects with a history of EDs (n = 118), assessed using both self-report and health records, were compared with those with no EDs (n = 419), who were attending the clinic mainly for primary prevention of metabolic and cardiovascular risk. Logistic regression analysis was performed to assess the association of childhood-onset obesity with development of an ED at a later age. Childhood-onset obesity, gender, maternal history of eating disorders, and dieting were associated with a positive history of EDs at a later age (p < .05). It is important to raise professional awareness of early symptoms of EDs in children with a history of obesity and treat them accordingly.
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Affiliation(s)
- Hellas Cena
- a Unit of Human Nutrition and Dietetics, Department of Public Health , Experimental and Forensic Medicine, University of Pavia , Pavia , Italy
| | - Fatima Cody Stanford
- b Departments of Medicine, Gastroenterology and Pediatrics, and Endocrinology , Massachusetts General Hospital and Harvard Medical School , Boston , Massachusetts , USA
| | - Luana Ochner
- a Unit of Human Nutrition and Dietetics, Department of Public Health , Experimental and Forensic Medicine, University of Pavia , Pavia , Italy
| | - Maria Luisa Fonte
- a Unit of Human Nutrition and Dietetics, Department of Public Health , Experimental and Forensic Medicine, University of Pavia , Pavia , Italy
| | - Ginevra Biino
- c Institute of Molecular Genetics , National Research Council of Italy , Pavia , Italy
| | - Rachele De Giuseppe
- a Unit of Human Nutrition and Dietetics, Department of Public Health , Experimental and Forensic Medicine, University of Pavia , Pavia , Italy
| | - Elsie Taveras
- d Division of General Academic Pediatrics, Department of Pediatrics , Massachusetts General Hospital for Children , Boston , Massachusetts , USA.,e Department of Nutrition , Harvard T.H. Chan School of Public Health , Boston , Massachusetts , USA
| | - Madhusmita Misra
- f Pediatric Endocrine and Neuroendocrine Units , Massachusetts General Hospital and Harvard Medical School , Boston , Massachusetts , USA
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Reyes Y, Paoli M, Camacho N, Molina Y, Santiago J, Lima-Martínez MM. Epicardial adipose tissue thickness in children and adolescents with cardiometabolic risk factors. ACTA ACUST UNITED AC 2015; 63:70-8. [PMID: 26654426 DOI: 10.1016/j.endonu.2015.09.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 09/07/2015] [Accepted: 09/08/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To assess the relationship of epicardial adipose tissue (EAT) thickness with cardiometabolic risk factors (CRFs) in children and adolescents. METHODS Seventy-seven subjects of both sexes aged 7-18 years were selected. Medical history, clinical parameters, and glucose, insulin, and lipid levels were collected. EAT thickness was measured using transthoracic echocardiography. Study subjects were divided into two groups based on whether they had less than two or two or more CRFs. RESULTS The group with two or more CRFs had higher EAT thickness, insulin, and HOMA-IR values (P<.05). EAT thickness showed a statistically significant positive correlation with body mass index (BMI) (r=0.561, P=.0001), waist circumference (r=.549, P=.0001), systolic blood pressure (SBP) (r=.256, P=.028), insulin (r=0.408, P=.0001), and HOMA-IR (r=.325, P=.005). However, these correlations were not significant after adjustment for BMI. The cut-off point for EAT thickness as predictor of two or more CRFs was 3.17mm. The risk (odds ratio) of having two or more CRFs if EAT thickness was >3.17mm was 3.1 (95% CI: 1.174-8.022). BMI was the independent variable that most affected EAT thickness and the presence of two or more CRFs. CONCLUSION In this group of children and adolescents, the relationship of EAT thickness with CRFs was found to be dependent on BMI.
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Affiliation(s)
- Yubriangel Reyes
- Unidad de Endocrinología, Instituto Autónomo Hospital Universitario de los Andes, Mérida, Venezuela
| | - Mariela Paoli
- Unidad de Endocrinología, Instituto Autónomo Hospital Universitario de los Andes, Mérida, Venezuela.
| | - Nolis Camacho
- Unidad de Nutrición, Crecimiento y Desarrollo Infantil, Instituto Autónomo Hospital Universitario de los Andes, Mérida, Venezuela
| | - Yudisay Molina
- Instituto de Investigaciones Cardiovasculares, Instituto Autónomo Hospital Universitario de los Andes, Mérida, Venezuela
| | - Justo Santiago
- Instituto de Investigaciones Cardiovasculares, Instituto Autónomo Hospital Universitario de los Andes, Mérida, Venezuela
| | - Marcos M Lima-Martínez
- Departamento de Ciencias Fisiológicas, Universidad de Oriente, Núcleo Bolívar, Ciudad Bolívar, Venezuela
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