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Evaluation of epicardial adipose tissue, carotid intima-media thickness and ventricular functions in obese children and adolescents

  • Hayrullah Alp EMAIL logo , Beray Selver Eklioğlu , Mehmet Emre Atabek , Sevim Karaarslan , Tamer Baysal , Hakan Altın , Zehra Karataş and Fatih Şap
Published/Copyright: April 16, 2014
Journal of Pediatric Endocrinology and Metabolism
From the journal Journal of Pediatric Endocrinology and Metabolism Volume 27 Issue 9-10

Abstract

Background: Childhood obesity is a cardiovascular risk factor.

Objective: Epicardial adipose tissue (EAT) thickness, carotid intima-media thickness (IMT) and cardiac functions of obese children and their correlations were evaluated.

Subjects: Five hundred obese children and 150 age- and sex-matched healthy controls.

Methods: Anthropometric, laboratory data and echocardiographic measurements of IMT, EAT and cardiac functions were determined.

Results: Increased M-mode echocardiographic measurements, E/e′ ratios, Tei index values and decreased E/A and e′/a′ ratios (where E and A are early and late mitral/tricuspid diastolic velocities, respectively, and e′ and a′ are peak early diastolic and peak atrial systolic myocardial velocities, respectively), were determined in the obese group. Also, carotid artery IMT and EAT thickness were significantly higher in obese children. Carotid artery IMT, EAT thickness and left ventricular mass (LVM) were found to be strongly associated with Tei index values.

Conclusion: Obesity is a major risk factor for cardiovascular diseases. In our study, we showed that obese children have early subclinical systolic and diastolic dysfunctions. Also, these cardiac impairments are correlated with the increase in IMT, EAT thickness and LVM.

Keywords: cardiac functions; children; epicardial adipose tissue; intima-media thickness; obesity, subclinical cardiac dysfunction
Corresponding author: Hayrullah Alp, MD, Malatya State Hospital, Department of Pediatric Cardiology, Malatya, Turkey, Phone: +00904222121010, Fax: +00904222121022, E-mail:

References

1. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, et al. Prevalence of overweight and obesity in the United States, 1999–2004. J Am Med Assoc 2006;295:1549–55.10.1001/jama.295.13.1549Search in Google Scholar PubMed

2. Olds T, Maher C, Zumin S, Péneau S, Lioret S, et al. Evidence that the prevalence of childhood overweight is plateauing: data from nine countries. Int J Pediatr Obes 2011;6:342–60.10.3109/17477166.2011.605895Search in Google Scholar PubMed

3. Farajian P, Risvas G, Karasouli K, Pounis GD, Kastorini CM, et al. Very high childhood obesity prevalence and low adherence rates to the Mediterranean diet in Greek children: the GRECO study. Atherosclerosis 2011;217:525–30.10.1016/j.atherosclerosis.2011.04.003Search in Google Scholar PubMed

4. Hughes AR, Sherriff A, Lawlor DA, Ness AR, Reilly JJ. Incidence of obesity during childhood and adolescence in a large contemporary cohort. Prev Med 2011;52:300–4.10.1016/j.ypmed.2011.02.014Search in Google Scholar PubMed PubMed Central

5. Sakai R. Relationship between prevalence of childhood obesity in 17-year-olds and socioeconomic and environmental factors: prefecture-level analysis in Japan. Asia Pac J Public Health 2013;25:159–69.10.1177/1010539511416347Search in Google Scholar PubMed

6. Yumuk VD. Prevalence of obesity in Turkey. Obes Rev 2005;6: 9–10.10.1111/j.1467-789X.2005.00172.xSearch in Google Scholar PubMed

7. Kelley RE, Dasmahapatra P, Wang J, Chen W, Srinivasan SR, et al. Prevalence of atherosclerotic plaque in young and middle-aged asymptomatic individuals: the Bogalusa heart study. South Med J 2011;104:803–8.10.1097/SMJ.0b013e318236c35cSearch in Google Scholar PubMed

8. Davis PH, Dawson JD, Riley WA, Lauer RM. Carotid intimal-medial thickness is related to cardiovascular risk factors measured from childhood through middle age: The Muscatine Study. Circulation 2001;104:2815–9.10.1161/hc4601.099486Search in Google Scholar PubMed

9. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med 1997;337:869–73.10.1056/NEJM199709253371301Search in Google Scholar PubMed

10. Poirier P, Giles TD, Bray GA, Hong Y, Stern JS, et al. Obesity and cardiovascular disease: pathophysiology, evaluation, and effect of weight loss. Arterioscler Thromb Vasc Biol 2006;26:968–76.10.1161/01.ATV.0000216787.85457.f3Search in Google Scholar PubMed

11. Lurbe E, Alvarez V, Redon J. Obesity, body fat distribution, and ambulatory blood pressure in children and adolescents. J Clin Hypertens (Greenwich) 2001;3:362–7.10.1111/j.1524-6175.2001.00492.xSearch in Google Scholar PubMed PubMed Central

12. Di Bonito P, Capaldo B, Forziato C, Sanguigno E, Di Fraia T, et al. Central adiposity and left ventricular mass in obese children. Nutr Metab Cardiovasc Dis 2008;18:613–7.10.1016/j.numecd.2007.09.002Search in Google Scholar PubMed

13. Mehta SK, Richards N, Lorber R, Rosenthal GL. Abdominal obesity, waist circumference, body mass index, and echocardiographic measures in children and adolescents. Congenit Heart Dis 2009;4:338–47.10.1111/j.1747-0803.2009.00330.xSearch in Google Scholar PubMed

14. Hacihamdioğlu B, Okutan V, Yozgat Y, Yildirim D, Kocaoğlu M, et al. Abdominal obesity is an independent risk factor for increased carotid intima-media thickness in obese children. Turk J Pediatr 2011;53:48–54.Search in Google Scholar

15. Litwin M, Niemirska A. Intima-media thickness measurements in children with cardiovascular risk factors. Pediatr Nephrol 2009;24:707–19.10.1007/s00467-008-0962-3Search in Google Scholar PubMed

16. Fang J, Zhang JP, Luo CX, Yu XM, Lv LQ. Carotid intima-media thickness in childhood and adolescent obesity relations to abdominal obesity, high triglyceride level and insulin resistance. Int J Med Sci 2010;7:278–83.10.7150/ijms.7.278Search in Google Scholar PubMed PubMed Central

17. Speiser PW, Rudolf MC, Anhalt H, Camacho-Hubner C, Chiarelli F, et al. Childhood obesity. J Clin Endocrinol Metab 2005;90:1871–87.10.1210/jc.2004-1389Search in Google Scholar PubMed

18. Charakida M, Tousoulis D, Stefanadis C. Early atherosclerosis in childhood: diagnostic approaches and therapeutic strategies. Int J Cardiol 2006;109:152–9.10.1016/j.ijcard.2005.06.010Search in Google Scholar PubMed

19. Davis PH, Dawson JD, Riley WA. Carotid intimal-medial thickness is related to cardiovascular risk factors measured from childhood through middle age: the Muscatine study. Circulation 2001;104:2815–9.10.1161/hc4601.099486Search in Google Scholar PubMed

20. Iacobellis G, Assael F, Ribaudo MC, Zappaterreno A, Alessi G, et al. Epicardial fat from echocardiography: a new method for visceral adipose tissue prediction. Obes Res 2003;11:304–10.10.1038/oby.2003.45Search in Google Scholar PubMed

21. Iacobellis G, Lonn E, Lamy A, Singh N, Sharma AM. Epicardial fat thickness and coronary artery disease correlate independently of obesity. Int J Cardiol 2011;146:452–4.10.1016/j.ijcard.2010.10.117Search in Google Scholar PubMed

22. Iacobellis G, Ribaudo MC, Assael F, Vecci E, Tiberti C, et al. Echocardiographic epicardial adipose tissue is related to anthropometric and clinical parameters of metabolic syndrome: a new indicator of cardiovascular risk. J Clin Endocrinol Metab 2003;88:5163–8.10.1210/jc.2003-030698Search in Google Scholar PubMed

23. Djaberi R, Schuijf JD, van Werkhoven JM, Nucifora G, Jukema JW, et al. Relation of epicardial adipose tissue to coronary atherosclerosis. Am J Cardiol 2008;102:1602–7.10.1016/j.amjcard.2008.08.010Search in Google Scholar PubMed

24. Rabkin SW. Epicardial fat: properties, function and relationship to obesity. Obes Rev 2007;8:253–61.10.1111/j.1467-789X.2006.00293.xSearch in Google Scholar PubMed

25. Iacobellis G, Corradi D, Sharma AM. Epicardial adipose tissue: anatomic, biomolecular and clinical relationships with the heart. Nat Clin Pract Cardiovasc Med 2005;2:536–43.10.1038/ncpcardio0319Search in Google Scholar PubMed

26. Sharpe JA, Naylor LH, Jones TW, Davis EA, O’Driscoll G, et al. Impact of obesity on diastolic function in subjects < or = 16 years of age. Am J Cardiol 2006;98:691–3.10.1016/j.amjcard.2006.03.052Search in Google Scholar PubMed

27. Dhuper S, Abdullah RA, Weichbrod L, Mahdi E, Cohen HW. Association of obesity and hypertension with left ventricular geometry and function in children and adolescents. Obesity (Silver Spring) 2011;19:128–33.10.1038/oby.2010.134Search in Google Scholar PubMed

28. Harada K, Orino T, Takada G. Body mass index can predict left ventricular diastolic filling in asymptomatic obese children. Pediatr Cardiol 2001;22:273–8.10.1007/s002460010228Search in Google Scholar PubMed

29. Nagueh SF, Appleton CP, Gillebert TC, Marino PN, Oh JK, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography. Eur J Echocardiogr 2009;10:165–93.10.1093/ejechocard/jep007Search in Google Scholar PubMed

30. Khankirawatana B, Khankirawatana S, Peterson B, Mahrous H, Porter TR. Peak atrial systolic mitral annular velocity by Doppler tissue reliably predicts left atrial systolic function. J Am Soc Echocardiogr 2004;17:353–60.10.1016/j.echo.2003.12.023Search in Google Scholar PubMed

31. Bundak R, Furman A, Gunoz H, Darendeliler F, Bas F, et al. Body mass index references for Turkish children. Acta Paediatr 2006;95:194–8.10.1080/08035250500334738Search in Google Scholar PubMed

32. Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, et al. Recommendations for chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr 2005;18:1440–63.10.1016/j.echo.2005.10.005Search in Google Scholar PubMed

33. Devereux RB, Reichek N. Echocardiographic determination of left ventricular mass in man. Anatomic validation of the method. Circulation 1977;55:613–8.Search in Google Scholar

34. Daniels SR, Loggie JM, Khoury P, Kimball TR. Left ventricular geometry and severe left ventricular hypertrophy in children and adolescents with essential hypertension. Circulation 1998;97:1907–11.10.1161/01.CIR.97.19.1907Search in Google Scholar PubMed

35. Tei C. New non-invasive index for combined systolic and diastolic ventricular function. J Cardiol 1995;26:135–6.Search in Google Scholar

36. Touboul PJ, Hennerici MG, Meairs S, Adams H, Amarenco P, et al. Mannheim carotid intima-media thickness consensus (2004–2006). An update on behalf of the Advisory Board of the 3rd and 4th Watching the Risk Symposium, 13th and 15th European Stroke Conferences, Mannheim, Germany, 2004, and Brussels, Belgium, 2006. Cerebrovasc Dis 2007;23:75–80.10.1159/000097034Search in Google Scholar PubMed

37. Cardiometabolic Risk Working Group: Executive Committee, Leiter LA, Fitchett DH, Gilbert RE, Gupta M, et al. Cardiometabolic risk in Canada: a detailed analysis and position paper by the Cardiometabolic Risk Working Group. Can J Cardiol 2011;27:1–33.10.1016/j.cjca.2010.12.054Search in Google Scholar PubMed

38. Chinali M, de Simone G, Roman MJ, Lee ET, Best GL, et al. Impact of obesity on cardiac geometry and function in a population of adolescents. The Strong Heart Study. J Am Coll Cardiol 2006;47:2267–73.10.1016/j.jacc.2006.03.004Search in Google Scholar PubMed

39. Janssen I, Katzmarzyk PT, Srinivasan SR, Chen W, Malina RM, et al. Combined influence of body mass index and waist circumference on coronary artery disease risk factors among children and adolescents. Pediatrics 2005;115:1623–30.10.1542/peds.2004-2588Search in Google Scholar PubMed

40. Kamal HM, Atwa HA, Saleh OM, Mohamed FA. Echocardiographic evaluation of cardiac structure and function in obese Egyptian adolescents. Cardiol Young 2012;22:410–6.10.1017/S1047951111001910Search in Google Scholar PubMed

41. Levent E, Gökşen D, Ozyürek AR, Darcan S, Coker M. Usefulness of the myocardial performance index (MPI) for assessing ventricular function in obese pediatric patients. Turk J Pediatr 2005;47:34–38.Search in Google Scholar

42. Van Putte-Katier N, Rooman RP, Haas L, Verhulst SL, Desager KN, et al. Early cardiac abnormalities in obese children: importance of obesity per se versus associated cardiovascular risk factors. Pediatr Res 2008;64:205–9.10.1203/PDR.0b013e318176182bSearch in Google Scholar PubMed

43. Zeybek C, Aktuglu-Zeybek C, Onal H, Altay S, Erdem A, et al. Right ventricular subclinical diastolic dysfunction in obese children: the effect of weight reduction with a low-carbohydrate diet. Pediatr Cardiol 2009;30:946–53.10.1007/s00246-009-9472-8Search in Google Scholar PubMed

44. Zeybek C, Celebi A, Aktuglu-Zeybek C, Onal H, Yalcin Y, et al. The effect of low-carbohydrate diet on left ventricular diastolic function in obese children. Pediatr Int 2010;52:218–23.10.1111/j.1442-200X.2009.02940.xSearch in Google Scholar PubMed

45. Saritas T, Tascilar E, Abaci A, Yozgat Y, Dogan M, et al. Importance of plasma N-terminal pro B-type natriuretic peptide, epicardial adipose tissue, and carotid intima-media thicknesses in asymptomatic obese children. Pediatr Cardiol 2010;31:792–9.10.1007/s00246-010-9705-xSearch in Google Scholar PubMed

46. Iacobellis G, Ribaudo MC, Zappaterreno A, Iannucci CV, Leonetti F. Relation between epicardial adipose tissue and left ventricular mass. Am J Cardiol 2004;94:1084–7.10.1016/j.amjcard.2004.06.075Search in Google Scholar PubMed

47. Ozdemir O, Hizli S, Abaci A, Agladioglu K, Aksoy S. Echocardiographic measurement of epicardial adipose tissue in obese children. Pediatr Cardiol 2010;31:853–60.10.1007/s00246-010-9720-ySearch in Google Scholar PubMed

48. Baysal T, Alp H, Koç N, Atabek ME, Eklioğlu BS, et al. Serum ischemia-modified albumin level and its association with cardiovascular risk factors in obese children and adolescents. J Pediatr Endocrinol Metab 2012;25:935–44.10.1515/jpem-2012-0191Search in Google Scholar PubMed

49. Freedman DS, Patel DA, Srinivasan SR, Chen W, Tang R, et al. The contribution of childhood obesity to adult carotid intima-media thickness: the Bogalusa Heart Study. Int J Obes (Lond) 2008;32:749–56.10.1038/sj.ijo.0803798Search in Google Scholar PubMed

50. Nambi V, Chambless L, He M, Folsom AR, Mosley T, et al. Common carotid artery intima-media thickness is as good as carotid intima-media thickness of all carotid artery segments in improving prediction of coronary heart disease risk in the Atherosclerosis Risk in Communities (ARIC) study. Eur Heart J 2012;33:183–90.10.1093/eurheartj/ehr192Search in Google Scholar PubMed PubMed Central

Received: 2013-7-21
Accepted: 2014-3-14
Published Online: 2014-4-16
Published in Print: 2014-9-20

©2014 by De Gruyter

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https://doi.org/10.1515/jpem-2013-0306
Keywords for this article
cardiac functions; children; epicardial adipose tissue; intima-media thickness; obesity, subclinical cardiac dysfunction

Articles in the same Issue

  1. Frontmatter
  2. Review article
  3. Towards an optimization of the management of endocrine complications of thalassemia
  4. Original articles
  5. The natural course of Hashimoto’s thyroiditis in children and adolescents
  6. Muscle strength and body composition during the transition phase in patients treated with recombinant GH to final height
  7. Benign vaginal bleeding in 24 prepubertal patients: clinical, biochemical and imaging features
  8. Evaluation of epicardial adipose tissue, carotid intima-media thickness and ventricular functions in obese children and adolescents
  9. Counseling patients with succinate dehydrogenase subunit defects: genetics, preventive guidelines, and dealing with uncertainty
  10. Pubertal development profile in patients with Turner syndrome
  11. A novel CASR mutation associated with neonatal severe hyperparathyroidism transmitted as an autosomal recessive disorder
  12. Serum insulin-like growth factor-binding protein-3 level correlated with glycemic control and lipid profiles in children and adolescents with type 1 diabetes
  13. Adult human liver mesenchymal progenitor cells express phenylalanine hydroxylase
  14. Clinical applicability of rapid detection of SRY and DYS14 genes in patients with disorders of sex development using an indigenously developed 5′ exonuclease based assay
  15. Hereditary 1,25-dihydroxyvitamin D-resistant rickets with alopecia in four Egyptian families: report of three novel mutations in the vitamin D receptor gene
  16. Permanent neonatal diabetes mellitus in Jordan
  17. The effect of adenotonsilectomy on ghrelin, leptin, IGF-1 levels and growth parameters in children with adenotonsillar hypertrophy
  18. The role of anti-Mullerian and inhibin B hormones in the evaluation of 46,XY disorders of sex development
  19. The evaluation of thyroid carcinoma in childhood and concomitance of autoimmune thyroid disorders
  20. Lipid patterns in treated growth hormone deficient children vs. short stature controls
  21. Assessment of aortic morphology and compliance in children and adolescents with Ullrich-Turner syndrome (UTS) using magnetic resonance imaging (MRI)
  22. Management of central diabetes insipidus with oral desmopressin lyophilisate in infants
  23. Maternal factors and complications of preterm birth associated with neonatal thyroid stimulating hormone
  24. Patient reports
  25. A rare case of pituitary infarction leading to spontaneous tumour resolution and CSF-sella syndrome in an 11-year-old girl and a review of the paediatric literature
  26. Rare case of homozygous epimerase deficiency and heterozygous of duarte 2 variant
  27. Persistent congenital hyperinsulinism in two patients with Beckwith-Wiedemann syndrome due to mosaic uniparental disomy 11p
  28. Growth hormone treatment in a patient with Hurler-Scheie syndrome
  29. Neonatal diagnosis of a patient with hypoparathyroidism, sensorineural deafness and renal dysplasia (HDR) syndrome associated with cerebral infarction
  30. Early-onset diabetes mellitus and neurodevelopmental retardation: the first Greek case of Wolcott-Rallison syndrome
  31. Type III Bartter-like syndrome in an infant boy with Gitelman syndrome and autosomal dominant familial neurohypophyseal diabetes insipidus
  32. Cushing’s syndrome: hidden risk in usage of topical corticosteroids
  33. Prader-Willi syndrome: a case report with atypical developmental features
  34. Berardinelli-Seip congenital lipodystrophy: an autosomal recessive disorder with rare association of duodenocolonic polyps
  35. Ectopic Cushing syndrome secondary to metastatic medullary thyroid cancer in a child with multiple endocrine neoplasia syndrome type 2B: clues to early diagnosis of the paraneoplastic syndromes
  36. Ovarian hyperstimulation syndrome treated by medroxyprogesterone acetate
  37. Symptomatic cerebral infarction in a child with severe diabetic ketoacidosis
  38. A rare case of familial Cushing’s syndrome with a common presentation of weight gain due to a mutation of the PRKAR1A gene causing isolated primary pigmented nodular adrenocortical disease
  39. Multiple autoimmunity, type 1 diabetes (T1DM), autoimmune thyroiditis and thyroid cancer: is there an association? A case report and literature review
  40. Cholestasis and protein-losing enteropathy secondary to hyperthyroidism in a 6-year-old girl
  41. Short communication
  42. An essential splice site mutation (c.317+1G>A) in the TSHR gene leads to severe thyroid dysgenesis
  43. Letter to the Editor
  44. Pubertal gynecomastia: what about the remaining 10%?
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