Tri-Ponderal Mass Index as a Screening Tool for Identifying Body Fat and Cardiovascular Risk Factors in Children and Adolescents: A Systematic Review

Evaluating eight indicators for identifying metabolic syndrome in Chinese and American adolescents

BACKGROUND

Early intervention and diagnosis of Metabolic Syndrome (MetS) are crucial for preventing adult cardiovascular disease. However, the optimal indicator for identifying MetS in adolescent remains controversial.

METHODS

In total,1408 Chinese adolescents and 3550 American adolescents aged 12-17 years were included. MetS was defined according to the modified version for adolescents based on Adult Treatment Panel III (NCEP-ATP III) criteria. Areas under the curve (AUC) and corresponding 95% confidence interval (95% CI) of 8 anthropometric/metabolic indexes, such as waist circumference (WC), body mass index (BMI), a body shape index (ABSI), waist triglyceride index (WTI), were calculated to illustrate their ability to differentiate MetS. Sensitivity analysis using the other MetS criteria was performed.

RESULTS

Under the modified NCEP-ATP III criteria, WTI had the best discriminating ability in overall adolescents, with AUC of 0.922 (95% CI: 0.900-0.945) in Chinese and 0.959 (95% CI: 0.949-0.969) in American. In contrast, ABSI had the lowest AUCs. Results of sensitivity analysis were generally consistent for the whole Chinese and American population, with the AUC for WC being the highest under some criteria, but it was not statistically different from that of WTI.

CONCLUSIONS

WTI had relatively high discriminatory power for MetS detection in Chinese and American adolescents, but the performance of ABSI was poor.

IMPACT

While many studies have compared the discriminatory power of some anthropometric indicators for MetS, there are few focused on pediatrics. The current study is the first to compare the discriminating ability of anthropometric/metabolic indicators (WC, BMI, TMI, ABSI, WHtR, VAI, WTI, and TyG) for MetS in adolescents. WTI remains the optimal indicator in screening for MetS in adolescents. WC was also a simple and reliable indicator when screening for MetS in adolescents, but the performance of ABSI was poor. This study provides a theoretical basis for the early identification of MetS in adolescents by adopting effective indicators.

Evaluation of body mass index, ponderal index, visceral cross-sectional area, subcutaneous fat cross-sectional area, and liver volume as predictive factors for obesity-related comorbidities: a retrospective cohort study

BACKGROUND

The body mass index (BMI) is an imperfect clinical measure of obesity that should be used in conjunction with other valid measures of weight-related risk. We studied whether there is a superior measure of obesity-related comorbidities.

METHODS

Records of bariatric clinic patients who had an abdominal computed tomography (CT) within 1 year of visit were reviewed. The presence of obesity-related comorbidities was determined at the time of the scan. BMI and ponderal index (PI) were calculated, and CT scans were reviewed to determine the visceral cross-sectional area (VCSA), subcutaneous fat cross-sectional area (SFCSA), and liver volume (LV). Data were analyzed using the Kruskal-Wallis test and Mann-Whitney U test.

RESULTS

A higher number of comorbidities were found to be associated with a larger BMI (P = .011), VCSA (P = .014), SFCSA (P = .007), and LV (P = .014), but not a larger PI (P = .11). Of the 16 comorbidities assessed, VCSA and LV were associated with more than BMI and SFCSA. However, each measure could be associated with different comorbidities. A higher BMI was associated with increased insulin use (P = .034), hypertension (P = .007), and history of obstructive sleep apnea (P = .015), none of which were associated with PI. BMI and PI were the only measures associated with a history of deep vein thrombosis/pulmonary embolism (both P < .01). Only SFCSA was found to be associated with gastroesophageal reflux disease (P = .029). VCSA (P = .038) and LV (P = .001) were associated with nonalcoholic fatty liver disease.

CONCLUSION

No measure could account for all obesity-related comorbidities, implying the need for targeted measurements. However, PI was the least effective measure.

The Association Between Obesity Measures and Metabolic Syndrome Risk in Korean Adolescents Aged 10-18 Years

Introduction

Childhood obesity is strongly linked to an increased risk of metabolic syndrome (MetS), type 2 diabetes, and cardiovascular disease in adulthood, endangering the global healthcare system. No single tool for detecting MetS is suitable for all pediatric populations. This study aimed to investigate the association between obesity measures and MetS in Korean children and adolescents.

Method and Materials

The data were obtained from 1663 children and adolescents aged 10-19 years (771 girls) who participated in the Fourth and Fifth Korea National Health and Nutrition Examination Surveys. Body mass index (BMI), waist circumference (WC), and waist-to-hip ratio (WHtR) were included as obesity measures. Fasting blood glucose, triglycerides, high-density lipoprotein cholesterol, and resting blood pressure were included as metabolic risk factors. MetS was defined as the clustering of metabolic risk factors such as elevated fasting blood glucose, elevated mean arterial pressure, elevated triglycerides, and low high-density lipoprotein cholesterol.

Results

Regardless of the obesity measures used, obese children and adolescents were more likely to have a clustering of metabolic risk factors compared to their non-obese counterparts: BMI-based obesity (odds ratio, OR=4.151, 95% confidence interval, CI=2.763~6.238, p<0.001), WC-based obesity (OR=1.917, 95% CI=1.066~3.446, p=0.010), and WHtR-based obesity (OR=2.160 and 95% CI=1.203~3.878, p=0.003). A receiver operating curve analysis showed that BMI (area under the curve, AUC=0.849, 95% CI=0.8270.871) outperformed WC (AUC=0.833, 95% CI=0.8090.856) and WHtR (AUC=0.794, 95% CI=0.7670.821) in detecting the presence of MetS.

Conclusion and Recommendation

Study findings suggest that obese teenagers are more likely to have metabolic syndrome than non-obese teens. Concerning accuracy, convenience, and ease of use and calculation, BMI is the best screening tool for detecting MetS in Korean children and adolescents.

Tri-ponderal mass index and left ventricular hypertrophy in a cohort of caucasian children and adolescents with obesity

BACKGROUND

Pediatric obesity is a global emerging burden for society; among its health-related consequences there are hypertension (HTN) and left ventricular hypertrophy (LVH). Several anthropometric indices have been investigated for the early identification of cardiovascular risk in children. The aim of the present study was to assess whether tri-ponderal mass index (TMI) was associated with LVH in a cohort of Caucasian children and adolescents with obesity.

METHODS

In this observational study, 63 children and adolescents with obesity aged 7-to-16 years were enrolled. During outpatient visits, adiposity, and cardio-metabolic indices (BMI z-score, WHR, TMI, ABSI) were collected. All subjects underwent a 24-hour ambulatory blood pressure monitoring (ABPM) and transthoracic echocardiography.

RESULTS

Children and adolescents with obesity with LVH had significantly higher BMI z-score (p = 0.009), WHR (p = 0.006) and TMI (p = 0.026) compared to children without LVH. WC and WHR were the only indices significantly associated with left ventricular mass index (LVMI).

CONCLUSION

Left ventricular remodeling is associated with the cardio-metabolic risk markers WC and WHR, but not with the adiposity index TMI among children with obesity.

Association between tri-ponderal mass index and glucose metabolism disorder in children with obesity in China: A case-control study

Obesity is a risk factor for glucose metabolism disorder. This study explored the association between the tri-ponderal mass index (TMI) and indicators of glucose metabolism disorder in children with obesity in China. This retrospective case-control study included children aged 3 to 18 years old diagnosed with obesity at Jiangxi Provincial Children's Hospital (China) between January 2020 and April 2022. Demographic and clinical characteristics were obtained from the medical records. Factors associated with glucose metabolism disorder were explored by logistic regression analysis. Pearson correlations were calculated to evaluate the relationships between TMI and indicators of glucose metabolism disorder. The analysis included 781 children. The prevalence of glucose metabolism disorder was 22.0% (172/781). The glucose metabolism disorder group had an older age (11.13 ± 2.19 vs 10.45 ± 2.33 years old, P = .001), comprised more females (76.8% vs 66.9%, P = .008), had a higher Tanner index (P = .001), and had a larger waist circumference (89.00 [82.00-95.00] vs 86.00 [79.00-93.75] cm, P = .025) than the non-glucose metabolism disorder group. There were no significant differences between the glucose metabolism disorder and non-glucose metabolism disorder groups in other clinical parameters, including body mass index (26.99 [24.71-30.58] vs 26.57 [24.55-29.41] kg/m2) and TMI (18.38 [17.11-19.88] vs 18.37 [17.11-19.88] kg/m3). Multivariable logistic regression did not identify any factors associated with glucose metabolism disorder. Furthermore, TMI was only very weakly or negligibly correlated with indicators related to glucose metabolism disorder. TMI may not be a useful indicator to screen for glucose metabolism disorder in children with obesity in China.

Combined training in addition to cortisol reduction can improve the mental health of girls with precocious puberty and obesity

Background

Obesity and central precocious puberty (CPP) are associated with increased anxiety, depression, and anger in girls. The contribution of exercise as an efficacious component in decreasing anxiety, depression, and anger has been increasingly recognized.

Objectives

This study aims to evaluate the effects of combined training on cortisol, anxiety, depression, and anger in overweight and obese girls with CPP.

Methods

The study involved 30 girls aged 7-9 years diagnosed with CPP (undergoing triptorelin treatment) and dealing with obesity. In addition, these girls scored higher than the cut-off line for anxiety, depression, and anger. The participants were divided into two groups, with 15 individuals in each group. The exercise group engaged in 60 min of combined aerobic and resistance training three times per week for a duration of 12 weeks. On the other hand, the control group did not receive any training. Throughout the study, the serum cortisol levels were measured in both groups. Anxiety, anger, and depression questionnaires were also completed at three different stages, namely, baseline, 12 weeks, and 16 weeks (after a 4-week period of detraining).

Results

In the exercise group, there was a significant decrease (P < 0.05) in cortisol serum levels and anxiety, depression, and anger scores. These changes were observed consistently during detraining (P > 0.05). However, in the control group, only the depression score significantly decreased (P < 0.05).

Conclusions

Based on the results, it can be concluded that combined training is a method to improve the mental health of CPP girls.

Clinical Trial Registration

https://en.irct.ir/trial/61990, identifier IRCT20170411033378N10.

Tri-ponderal mass index as a screening tool for obesity prediction in children aged 6-9 years

Objective

This study aimed to evaluate the efficiency of tri-ponderal mass index (TMI) in determining obesity in Chinese children aged 6-9 years, using the criteria of percentage of body fat (PBF) and body mass index z-scores (BMI-Z).

Methods

The cross-sectional study included 5365 children, aged 6-9 years, who participated in the project survey "Group prevention and treatment of obesity among students and school health promotion in Shanghai" from September 2007 to September 2009. Height, weight, waist circumference, body mass index (BMI), TMI, waist-to-height ratio (WHtR), and PBF were recorded. Statistical analyses including Kolmogorov-Smirnov test, chi-square test, receiver operating characteristics curve, and kappa chi-square test were performed.

Results

TMI for both sexes was relatively constant with increasing age, and statistically significant differences were not observed at some ages (P > 0.05 at 6, 7, 8, and 9 years). WHtR showed subtle changes, while BMI and PBF increased significantly with age in boys and girls (P < 0.01). Using BMI-Z criteria as the measure of general obesity, the results indicated that TMI cutoff values for 6-9 years were 14.60 kg/m3 for boys and 14.84 kg/m3 for girls (P < 0.001). Analysis of the agreement between TMI and BMI-Z showed that the kappa statistic was 0.826 in boys and 0.709 in girls (P < 0.001).

Conclusion

TMI, as a constant tool, holds great potential as an alternative screening method for identifying children aged 6-9 years who may be at risk of obesity at an early stage.

Associations between tri-ponderal mass index, body mass index, and high blood pressure among children and adolescents: a cross-sectional study

High blood pressure (HBP) and obesity are major public health issues globally. The aim of the study was to evaluate the associations between tri-ponderal mass index (TMI) and body mass index (BMI) and HBP and to determine which anthropometric parameters may best predict HBP among Lithuanian children and adolescents aged 7-18 years. This cross-sectional study included 3710 Lithuanian children and adolescents aged 7-18 (52.7% boys and 47.3% girls). Each subject's height, weight, and other anthropometric parameters, as well as blood pressure were measured according to standardized protocols; subsequently, TMI and BMI were calculated. The prevalence of HBP was 27% (the prevalence of elevated BP and hypertension was 13.7% and 13.3%, respectively), significantly higher for boys than for girls. The Pearson correlation coefficients between the BMI z-score and BP were higher than those between the TMI z-score and BP. In both sexes combined, the adjusted odds ratios (aOR) for HBP were increased significantly with increasing quartiles of TMI and BMI as compared to the first quartile (Q1) (Q2: aOR = 1.37 and aOR = 1.69; Q3: aOR = 2.10 and aOR = 2.27; Q4: aOR = 3.95 and aOR = 4.91, respectively). Significant associations also were observed between overweight and obesity (defined according to two methods: age- and sex-specific TMI percentiles and IOTF criteria) among boys and girls separately. BMI presented a higher area under the curve value than TMI for predicting HBP in children and adolescents. The findings of the study suggest that BMI and TMI are significantly associated with HBP. However, BMI is a better predictor for HBP than TMI among Lithuanian children and adolescents aged 7-18 years.

Comparison of Several Anthropometric Indices Related to Body Fat in Predicting Cardiorespiratory Fitness in School-Aged Children-A Single-Center Cross-Sectional Study

Body fat (BF) and cardiorespiratory fitness (CRF) are important health markers that ought to be considered in screening exams. The aim of this study was to assess the value of six indicators, i.e., tri-ponderal mass index (TMI), relative fat mass (RFM), waist-BMI ratio, waist-to-height ratio (WHtR), waist-to-hip ratio (WHR) and body mass index (BMI) in predicting CRF in school-aged children. The analysis was based on the data coming from the examination of 190 children participating in school physical education (PE) classes. Their body weight (BW) and height (BH), waist and hip circumference (WC; HC) and percentage of body fat (%BF) were measured; the CRF test was performed with the use of the 20 m shuttle run test (20 mSRT); peak heart rate (HRpeak) was measured; TMI, relative fat mass pediatric (RFMp), waist-BMI ratio, WHtR, BMI and WHR were calculated. Statistical analysis was mainly conducted using regression models. The developed regression models, with respect to the sex and age of the children, revealed RFMp as the strongest CRF indicator (R2 = 51.1%) and WHR as well as waist-BMI ratio as the weakest ones (R2 = 39.2% and R2 = 40.5%, respectively). In predicting CRF in school-aged children, RFMp turned out to be comparable to body fat percentage obtained by means of the bioimpedance analysis (BIA) (R2 = 50.3%), and as such it can be used as a simple screening measure in prophylactic exams of school children. All of these models were statistically significant (p < 0.001).

Triponderal mass index and markers of metabolic risk in children and adolescents with obesity

BACKGROUND AND OBJECTIVE

Triponderal mass index (TMI) would estimate excess adiposity better than body mass index (BMI), maintaining stable values during childhood. This work aims to determine the correlation between TMI and markers of metabolic risk as well as set values of TMI that are related to an increase of metabolic risk.

MATERIAL AND METHODS

Multicenter, observational, cross-sectional and prospective study in children under 14 years of age with obesity.

VARIABLES

age, sex, pubertal stage, weight, height, abdominal circumference, BMI, TMI, basal glucose and insulin, HOMA index, blood pressure, lipoprotein profile, transaminases and uric acid. BMI and TMI were expressed according to the values of the Barcelona longitudinal study. Statistical analysis was performed with the SPSS* program.

RESULTS

One hundred and ninety-nine patients (50.3% male), age 11.08 (2.48) years, TMI 19.68 (2.36)kg/m³. Correlation between TMI and abdominal circumference (r=0.571; p=0), insulin (r=0.198; p=0.005), HOMA index (r=0.189; p=0.008) and HDL-c (r=-0.188; p=0.008) was observed. IMT>20.15kg/m³ was associated with insulin≥15mIU/ml (p=0.029) and IMT>20.36kg/m³ with HDL-c<40mg/dl (p=0.023).

CONCLUSIONS

TMI was correlated with increase of abdominal circumference, insulin and HOMA index and decrease of HDL-c. IMT>20kg/m³ can be associated with increased insulin and decreased HDL-c. Therefore, the IMT seems to be a useful parameter in the assessment of pediatric patients with obesity.

Comparisons of tri-ponderal mass index and body mass index in discriminating hypertension at three separate visits in adolescents: A retrospective cohort study

OBJECTIVE

To estimate whether the new obesity indicator tri-ponderal mass index (TMI) has a better capacity to predict adolescent hypertension (HTN) and HTN subtypes at three separate blood pressure (BP) visits than the conventionally used body mass index (BMI).

METHODS

A total of 36,950 adolescents who had initial normal BP from 2012 to 2019 were included in Suzhou, China. HTN was defined as having three separate visits of elevated BP in 2020. The area under the receiver-operating characteristic curve (AUC), false-positive rate, false-negative rate, total misclassification rates, net reclassification improvement (NRI), and integrated discrimination improvement were calculated to compare the discriminative ability of HTN between BMI and TMI.

RESULTS

TMI had better predictive abilities than BMI among all of the participants when predicting HTN (difference in AUC = 0.019, 95% CI = 0.007-0.031; NRI = 0.067, 95% CI = 0.008-0.127) and isolated systolic hypertension (difference in AUC = 0.021, 95% CI = 0.005-0.036; NRI = 0.106, 95% CI = 0.029-0.183). The difference in prediction abilities between BMI and TMI was more obvious in the subgroup of age ≥16. Also, TMI outperformed BMI in predicting adolescent HTN in girls but not in boys.

CONCLUSION

Compared with BMI, TMI may have a better predictive capacity for HTN, particularly in girls and older adolescents. TMI has the potential to be used as an effective predictor for HTN in clinic practice. Further studies are needed to verify the utility of TMI.

Predicting of excess body fat in children

PURPOSE OF REVIEW

Approximately 370 million children and adolescents worldwide showed overweight or obesity in 2016. The risk of developing severe comorbidities depends on the age of onset and the duration of obesity. This review discusses available methodologies to detect excess body fat in children as well as the early life factors that predict excess body fat and its development.

RECENT FINDINGS

Factors, such as parental nutritional status, maternal weight gain during pregnancy, maternal malnutrition, maternal smoking during pregnancy, low and high birth weight, rapid weight gain, and short infant sleep duration have been independently and positively associated with neonatal, infant, and children adiposity. Early detection of excess body fat in children through the use of various tools is the first step in preventing nutrition-related diseases in adulthood.

SUMMARY

The early detection of excess body fat and the implementation of efficient interventions to normalize the weight of children and adolescents at obesity risk are essential to prevent diseases in adult life.

A performance review of novel adiposity indices for assessing insulin resistance in a pediatric Latino population

INTRODUCTION

Body mass index (BMI) percentile or BMI adjusted for age and sex is the most common anthropometric index to monitor and assess obesity in children. However, the ability of BMI to accurately predict insulin resistance (IR) in youth is debated. Determining the best method to noninvasively measure IR in the pediatric population is especially important due to the growing prevalence of type 2 diabetes mellitus (T2DM), which is more likely to develop in people with IR. Therefore, this study analyzed the performance of BMI against newer anthropometric indices in assessing IR in a pediatric Latino identifying sample.

METHODS

We studied 127 pediatric Latino participants from the Arizona Insulin Resistance (AIR) registry and performed linear regression analyses between various measures of IR and adiposity indices, including body mass index (BMI), triponderal mass index (TMI), body adiposity index (BAI), pediatric body adiposity index (pBAI), a body shape index (ABSI), abdominal volume index (AVI), waist to height ratio (WtHR) and waist to hip ratio (WHR). Log transformations of each index adjusted for age and sex and IR were used for the linear regressions. Additionally, we generated receiver operating characteristics (ROC) from logistic regressions between HOMA-IR and HOMA2IR against the same indices.

RESULTS

Using the homeostatic assessment of insulin resistance (HOMA-IR), HOMA2IR, the quantitative insulin-sensitivity check index (QUICKI), fasting serum insulin, and FPG/FSI to measure IR, we showed that BMI adjusted for age and sex performs similarly to many of the newer indices in our sample. The correlation coefficients for pBAI [R2: 0.27, 95% confidence interval: 0.88-1.81, p < 0.001] and BMI [R2: 0.27, 95% confidence interval: 0.92-1.92, p < 0.001] were the highest for HOMA-IR. Similarly, pBAI [R2: 0.29, 95% confidence interval: 0.88-1.72, p < 0.001] and BMI [R2: 0.29, 95% confidence interval: 0.93-1.83, p < 0.001] were the highest for HOMA2IR. A similar trend was observed with QUICKI, FSI, and FPG/FSI. ABSI had the lowest R ² value for all measures of IR. Area under the curve (AUC) values for the receiver operating characteristics (ROC) for HOMA-IR and HOMA2IR support these conclusions.

CONCLUSIONS

BMI adjusted for age and sex, despite its usage and simplicity, still stacks up well against newer indices in our Latino sample. Testing these indices across larger samples is necessary to generalize these findings and translate performance to adults.