**2. Methods**

**1. Introduction**

**Study Excess**

Weiss et al. [14]BMI ≥ 97th

Cook et al. [12]

De Ferranti et al. [13]

Cruz et al. [15]

Viner et al. [16]

Ford et al. [17]

[18]

[19]

Lambert et al.

Zimmet et al.

feeding habits and lifestyle [3, 4].

150 Adiposity - Epidemiology and Treatment Modalities

**adiposity**

WC ≥ 90th percentile

WC ≥ 75th percentile

percentile

WC ≥ 90th percentile

BMI ≥ 95th percentile

WC ≥ 90th percentile

BMI ≥ 85th percentile

WC ≥ 90th percentile

SBP or DBP ≥ 90th percentile

SBP or DBP ≥ 90th percentile

SBP or DBP ≥ 90th percentile

SBP ≥ 130 or DBP ≥ 85 mmHg

chol, high-density lipoprotein cholesterol; OGTT, oral glucose tolerance test.

metabolic syndrome when three or more of the following characteristics were present).

Childhood obesity represents the most relevant nutritional disorder in our environment [1, 2]. It usually initiates at early stages in life, when child feeding depends—almost exclusively—on feeding habits and preferences in a family setting; it is subsequently exacerbated (by the time of school attendance and/or adolescence), probably in relation to the adoption of unhealthy

SBP ≥ 90th percentile Triglycerides ≥ 100 mg/dl

SBP ≥ 95th percentile Triglycerides ≥ 95th percentile

SBP ≥ 95th percentile Triglycerides ≥ 150 mg/dl or

SBP ≥ 75th percentile Triglycerides ≥ 90th percentile

WC, waist circumference; BMI, body mass index; SBP, systolic blood pressure; DBP, diastolic blood pressure; HDL-

**Table 1.** Criteria for the diagnosis of the pediatric metabolic syndrome (all definitions considered a child as having the

Additional studies—except for uncommon situations such as endocrine, genetic or metabolic pathologies, which justify excess body weight—are used for the diagnosis and/or early detection of metabolic complications and, particularly, the metabolic syndrome. This syndrome is characterized by a cluster of symptoms associated with obesity, such as insulin resistance, arterial hypertension (HTA) and dyslipidemia, and its interest lies in the high

**Hypertension Dyslipidemia Abnormal glucose**

Triglycerides ≥ 110 mg/dl or HDL-chol ≤ 40 mg/dl

or HDL-chol ≤ 5th percentile

Triglycerides ≥ 90th percentile or HDL-C ≤ 10th percentile

HDL-chol ≤35 mg/dl or total-chol ≥ 95th percentile

Triglycerides ≥ 110 mg/dl or HDL-chol ≤ 40 mg/dl

or HDL-C ≤ 10th percentile

Triglycerides ≥ 75th percentile or HDL-chol ≤ 25th percentile

HDL-chol ≤ 50 mg/dl

**homeostasis**

(pubertal)

percentile

Fasting glucose ≥ 110 mg/dl

Fasting glucose ≥ 110 mg/dl

OGTT: glucose at 120 min >140 and <200 mg/dl

OGTT: glucose at 120 min >140 and <200 mg/dl

Fasting glucose ≥ 110 mg/dl or OGTT: glucose >140 and <200 at 2 h or fasting insulin ≥15 mU/L (prepubertal) or ≥30

Fasting glucose ≥ 110 mg/dl

Fasting glucose ≥ 110 mg/dl or

Fasting glucose ≥ 110 mg/dl

fasting insulin ≥ 75th

### **2.1. Patients**

A clinical assessment and metabolic study was accomplished in all patients diagnosed with obesity who attended follow-up consultation within the year 2014. Clinical evaluation was conducted in one of the three offices of the Pediatric Endocrinology Unit of the Navarra Hospital Complex. Pubertal stage was determined in each patient according to Tanner's criteria, and patients were classified into two different groups: prepubertal group (Tanner stage I) and pubertal group (Tanner stages II–V).

All those patients with personal history of endocrine disease, malformation syndromes or iatrogenic obesity (drug treatments) were excluded.

The metabolic syndrome was defined by modified Cook's criteria [12] as the manifestation of at least three of the following features: low HDL-cholesterol (<40 mg/dl), hypertriglyceridemia (TG > 110 mg/dl), obesity, arterial hypertension and insulin resistance.

#### **2.2. Clinical assessment**

The assessment of weight and height was accomplished in underwear and barefoot. Weight was measured using an Año-Sayol scale, with a reading interval of 0–120 kg and precision 100 g, and height was measured using a Holtain wall stadiometer ranging 60–210 cm and precision 0.1 cm. Body mass index (BMI) was calculated according to the corresponding formula: weight (kg)/height2 (m). Values of *Z* score for BMI were calculated using a nutrition application (Aplicación Nutricional) program from the Spanish Society of Pediatric Gastroenterology, Hepatology and Nutrition (available at http://www.gastroinf.es/nutritional/). The inclusion criterion was BMI (*Z* score) values exceeding +2.0 (97th percentile) by age and sex according to the growing charts from Ferrández et al. (Centro Andrea Prader, Zaragoza 2002) [33].

Blood pressure (BP) was measured in the right arm with the patient in the supine position using Visomat comfort 20/40 (Roche Diagnostics Inc.) digital blood pressure monitor, recording the lowest of three measurements. Arterial hypertension (HTA) was considered when systolic blood pressure (SBP) and/or diastolic blood pressure (DBP) was equal to or higher than 95th percentile by age, sex and height from the American reference charts (National high blood pressure Program in Children and Adolescents) [34].

The institutionalized program for Child Care in the Community of Navarre (Comunidad Foral de Navarra, Spain) includes periodic health examinations at ages 1, 2, 3, 4, 6, 8, 10 and 12 years. The anthropometric measurements (weight and height) are recorded in the corresponding clinical history. This record has allowed the registration of the age of onset for obesity and the time of evolution at the moment of the examination.

#### **2.3. Metabolic study**

Plasma concentrations for glucose, insulin, triglycerides, total cholesterol (total-chol), highdensity lipoprotein cholesterol (HDL-chol), low-density lipoprotein cholesterol (LDL-chol) and leptin were measured under basal fasting conditions using standardized methodologies.

In order to determine insulin resistance, the homeostasis model-assessment (HOMA) indexes were calculated from fasting glucose and insulin concentrations (glucose levels in mmol × insulin in μUml/L/22.5). Insulin resistance was considered when HOMA value was equal to or higher than 3.8 [35].

#### **2.4. Statistical analysis**

Results are displayed as percentages (%) and means (M) with corresponding standard deviations (SDS). Statistical analysis (descriptive statistics, Student's *T*, chi-square test and Pearson's correlation) was done using the Statistical Packages for the Social Sciences version 20.0 (Chicago, IL, USA). Statistical significance was assumed when *p* value was lower than 0.05.

Parents and/or legal guardians were informed and provided verbal consent for the participation in this study in all cases. The study was approved by the Ethics Committee for Human Investigation at our institution.
