TECHNICAL REPORT

Appraisal of Clinical Care Practices for

Child Obesity Treatment. Part II:
Comorbidities
Asheley C. Skinner, PhD,a Amanda E. Staiano, PhD, MPP,b Sarah C. Armstrong, MD, FAAP,c Shari L. Barkin, MD, MSHS,d
Sandra G. Hassink, MD, FAAP,e Jennifer E. Moore, PhD, RN, FAAN,f Jennifer S. Savage, PhD,g Helene Vilme, DrPH,h
Ashley E. Weedn, MD, MPH, FAAP,i Janice Liebhart, MS,j Jeanne Lindros, MPH,k Eileen M. Reilly, MSWl

The objective of this technical report is to provide clinicians with abstract

actionable evidence-based information upon which to make treatment a
Department of Population Health Sciences, Duke University School of
decisions. In addition, this report will provide an evidence base on Medicine, Durham, North Carolina; bLouisiana State University
which to inform clinical practice guidelines for the management and Pennington Biomedical Research Center, Baton Rouge, Louisiana;
c
treatment of overweight and obesity in children and adolescents. Departments of Pediatrics and Population Health Sciences, Duke
Clinical Research Institute, Duke University, Durham, North Carolina;
d
To this end, the goal of this report was to identify all relevant studies to Children’s Hospital of Richmond at Virginia Commonwealth University,
Richmond, Virginia; eMedical Director, American Academy of
answer 2 overarching key questions: (KQ1) “What are effective Pediatrics, Institute for Healthy Childhood Weight, Wilmington,
clinically based treatments for obesity?” and (KQ2) “What is the risk of Delaware; fInstitute for Medicaid Innovation, University of Michigan
Medical School, Ann Arbor, Michigan; gCenter for Childhood Obesity
comorbidities among children with obesity?” See Appendix 1 for the Research, Pennsylvania State University, Department of Nutritional
conceptual framework and a priori Key Questions. Sciences, Pennsylvania State University, University Park, Pennsylvania;
h
Department of Population Health Sciences, Duke University School of
Medicine, Durham, North Carolina; iDepartment of Pediatrics,
University of Oklahoma Health Sciences Center, Oklahoma City,
Oklahoma; jAmerican Academy of Pediatrics, Itasca, Illinois; kAmerican
INTRODUCTION Academy of Pediatrics, Itasca, Illinois; and lAmerican Academy of
Obesity is a common concern in pediatric practice. In caring for Pediatrics, Itasca, Illinois

patients with obesity or patients who may be at risk for developing This document is copyrighted and is property of the American
obesity, clinicians have many unanswered questions. Examples of these Academy of Pediatrics and its Board of Directors. All authors have
filed conflict of interest statements with the American Academy of
questions include: What is the best way to identify excess adiposity, Pediatrics. Any conflicts have been resolved through a process
and does the identification of obesity provide opportunities for approved by the Board of Directors. The American Academy of
Pediatrics has neither solicited nor accepted any commercial
treatment? If so, what evidence-based interventions for obesity involvement in the development of the content of this publication.
treatment, delivered at least in part by clinicians in office-based Technical reports from the American Academy of Pediatrics benefit
settings, are most effective? Among children and adolescents identified from expertise and resources of liaisons and internal (AAP) and
external reviewers. However, technical reports from the American
as having obesity, does screening for comorbidities result in improved Academy of Pediatrics may not reflect the views of the liaisons or
health outcomes? the organizations or government agencies that they represent.
The guidance in this report does not indicate an exclusive course
of treatment or serve as a standard of medical care. Variations,
Many previous studies, most notably conducted by the US Preventive
Services Task Force, have synthesized research regarding the treatment
of obesity.1 Unfortunately, some important gaps remain unfilled. The To cite: Skinner AC, Staiano AE, Armstrong SC, et al. AAP
US Preventive Services Task Force recommendation was that obesity Appraisal of Clinical Care Practices for Child Obesity
Treatment. Part II: Comorbidities. Pediatrics. 2023;151(2):
treatment should include at least 26 hours of contact, including clinical e2022060643
care and other behavioral intervention (eg, guided physical activity).

PEDIATRICS Volume 151, number 2, February 2023:e2022060643 FROM THE AMERICAN ACADEMY OF PEDIATRICS
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 However, subsequent studies have METHODS investigation for false-positive
failed to demonstrate a consistent screening results. We will examine
Scope of the Review
hours-based dose-response. In specific conditions previously
addition, feasibility studies have This review was designed to answer recommended or that would
clearly shown how unrealistic it is 2 overarching key questions: reasonably require screening, as
for primary care or tertiary care (KQ1) “What are effective identified by the authors:
providers to deliver this many clinic-based treatments for obesity?” dyslipidemia, hypertension, diabetes,
hours of treatment in real-world, and (KQ2) “What is the risk of liver function, depression, sleep
clinical settings.2 Additional comorbidities among children with apnea, and asthma. This is not
information is needed about obesity?” We developed this focus intended to be a comprehensive list
resources or partnerships that based on the needs of clinicians and of all conditions comorbid with
help reach that contact hour the evidence required to inform the obesity but represents those most
future development of clinical common and for which screening is
goal, the essential components
practice guidelines. This review will potentially helpful.
delivered during these contact
not attempt to quantify the
hours, the period of time over Search Strategy
magnitude of the effect of obesity on
which this care is delivered,
child or adult outcomes. It will also We searched Pubmed and CENTRAL
and information about lower-
not attempt to address treatment (for trials), completing the final
intensity strategies with some
strategies for comorbidities search on April 6, 2018. An
effectiveness.
(eg, hypertension), as other additional search was conducted to
guidelines and reviews are available update the review, covering the time
Of particular concern for primary
to guide such treatment. period April 7, 2018, through
care pediatricians is the need to
understand how to approach February 15, 2020. We combined
Rationale for KQ1 (Intervention Studies)
recommendations for screening the searches for both key questions
comorbidities in their patients Clinicians are a regular source of because of significant overlap and to
trusted information for parents, more efficiently review studies.
with obesity. Although previous
including issues related to nutrition Because our focus was on
recommendations have supported
and activity, which are key interventions that are relevant to
screening for common
components of obesity prevention primary care, we did not search
comorbidities, such as
and treatment. Clinicians need to other databases, such as ERIC or
dyslipidemia and diabetes, there
know what strategies have high- PsycInfo.
has been conflicting evidence
quality evidence for effectiveness in
regarding timing and effectiveness
preventing and treating obesity. The complete search strategies are
of screening. Additional data
Additionally, physicians need included in Appendix 2. Briefly, we
are now available that provide guidance on which treatments are searched for studies of children or
clinicians and researchers with effective for their patient population adolescents, with a focus on
information about comorbidity and how to use available resources. overweight, obesity, or weight
prevalence and severity by The full results of KQ1 are reported status; involving clinicians, health
obesity class. The intent is to help in an accompanying technical care, or other treatment or
the clinician screen for report.3 screening (KQ1); and examining
comorbidities when there is a high common comorbidities (KQ2). For
likelihood of detecting an Rationale for KQ2 (Comorbidity Studies) both questions, we limited only
abnormality and when detection of Previous recommendations have using key words, not filters, to
that abnormality leads to treatment included assessments of ensure we included the newest
options that can improve child comorbidities, including studies that were not yet fully
health. Obesity classifications, hypertension, dyslipidemia, glucose, indexed. No date limits were placed
including a more granular and others. It is not clear whether on searches. In practice, this meant
categorization of obesity as classes I these assessments identify we reviewed studies from 1950 to
through III, might assist clinicians in important health conditions or lead 2020, although <2% were published
determining for whom screening to improved treatment strategies. before 1980.
would be most useful rather than Additionally, it is not clear whether
viewing screening as a conducting these assessments would Inclusion Criteria
homogeneous approach for anyone result in an adverse patient The complete inclusion criteria are
whose BMI is >95th percentile. outcomes, such as further included in Appendix 3.

2 SKINNER et al
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 17033 references imported for screening 1045 duplicates removed

15988 studies screened against tle and abstract 14346 studies excluded

1642 studies assessed for full-text eligibility

1260 studies excluded

290 EX1: Not original research
183 EX5: (KQ1) Primary aim not to compare comorbidity
by obesity
170 EX10: (KQ2-3) Not clinic or health care system
based
120 EX6: (KQ1) No prevalence reported
110 EX8: (KQ1) No BMI comparators
83 EX4: Not children 2-18
77 EX3: Not OECD country
75 EX9: (KQ2-3) No comparison group
28 EX2: Not English
382 studies included: 33 EX7: (KQ1) Wrong comorbidity measure(s)
28 EX13: (KQ2-3) Outcomes less than 3 months/12
215 Intervenon studies weeks/90 days
- 126 Lifestyle RCTs 28 EX12: (KQ2-3) Primary outcome is not obesity
o 54 w/ true control 18 EX11: (KQ2-3) Intervenon does not primarily
o 72 Comparave effecveness address obesity
- 27 Rx Trials 13 Unavailable
- 43 Observaonal lifestyle 3 EX14: Exogenous or medicaon-induced obesity
- 8 Observaonal Rx
- 11 Surgical 167

Comorbidity studies

FIGURE 1
PRISMA Diagram.

Inclusion Criteria Common to All Studies associated with obesity. All studies reflect the practice of clinical
All studies were required to include had to originate from the screening. Obesity had to be
children ages 2 to 18 years, Organization for Economic categorized using a BMI-based
although studies could also include Cooperation and Development measure into accepted categories
young adults up to age 25 if member countries and had to be (ie, healthy weight, overweight,
stratified from older adult available in English. class I obesity, class II obesity,
participants, as long as children class III obesity).
Inclusion Criteria for KQ2 (Comorbidity
under 18 were also included.
Children could have other
Studies) These categories could be based on
conditions (eg, asthma) as long as We included studies with a primary percentiles or z-scores and could
they were not known to cause aim of comparing comorbidities use the distributions relevant to the
obesity, such as Prader-Willi among those with and without studied population (eg, World
syndrome, obesogenic medication obesity or by severity of obesity. Health Organization [WHO] or the
(eg, antipsychotics), or known Obesity and the comorbidity had to US Centers for Disease Control and
genetic mutations (eg, MC4R) be measured contemporaneously to Prevention [CDC]). Comorbidities

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TABLE 1 Prevalence of Abnormal HDL (n 5 39)
First Author Country Ages (y) N Definition of Abnormal Subgroup (eg, M/F) Total Healthy Overweight Class I Class II Class III P Weight Definitions Population Info

Kim Korea 10–19 931 <40 mg/dL 35.8 31.2 50.6 55.0 <.0001
Halley Castillo Mexico 7–24 1366 <45 mg/dL males; 83% 90.8% <.000
<50 mg/dL females
Ice USA Mean 10.8 23263 <40 mg/dL 18.7 9.7 18.7 30.5 42.7 <.05
Ice USA 9–13 29286 <40 mg/dL 10.2 18.7 32.5 <.01
Duncan USA 12–19 991 <40 mg/dL 18.6 29.1 39.1 NHANES 1999–2000
Davis USA 7–18 160 <50 mg/dL females, 30 56 57 <.005
<40 mg/dL males
Bell Australia 6–13 283 <0.9 mmol/L 5.8 5.0 15.8 .203
Bindler USA 11–14 151 <35 mg/dL 13.6 29.3 .026
NCHS USA 12–19 3125 <35 mg/dL 7.6 4.3 8.3 20.5 <.05 1999–2006 NHANES
Turchiano USA 14–18 1185 <40 mg/dL 13.2 23.8 38.9 <.001 Patients of urban
minoritized
groups
Skinner USA 6–17 NR <35 mg/dL 6.0 3.0 8.7 15.5 <.01 NHANES 2001–2002
Simsek Turkey Mean 10.8 115 <35 mg/dL 0 9 .089
Salvatore USA 3–18 101 <50 mg/dL 33.3 67.9 85.7 87.1 .123
Propst USA Mean 12.7 1111 <45 mg/dL 17.9 20.7 .3169
Perez USA 12–18 101 24.5 52.1 <.004
O’Hara USA 3–19 382 <45 mg/dL 55 54 50 48 66 NS Pediatric weight
management
program
patients
Nguyen, D USA 6–19 NR <40 mg/dL 13.4% 6.8% 14.8% 33.2% <.05 NHANES 2011–2014

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Marcus USA Mean 11.2 1305 <40 mg/dL 27.2 38.9 <.0001
Michalsky USA 13–19 242 <30 mg/dL 16 17.7 15.6 12.5 .76 1: BMI 30–50, Bariatric surgery
2: BMI 50–60, patients
3: BMI >60
Yoshinaga Japan 6–12 471 <40 mg/dL Male 5.4 6.1
Female 8.3 8.8
Skinner USA 3–19 8579 <35 mg/dL 6.13 11.40 18.18 19.53 <.001 NHANES 1999–2012
Maximova Canada 6–19 2087 <25th 6–11 y 20.4 36.9 NR
<25th 12–19 y 20.6 41.4 NR
Li USA 3–19 20905 <40 mg/dL 8.86 18.23 25.78 39.97 <.05
Park Korea 10–19 1554 <35 mg/dL 21.2 26.9 41.2 <.05 OB 2007–2008
KNHANES
Laurson USA 12–18.9 3385 Joliffe standards Males 17.2 30.7 56.1 NR NHANES
Females 32.9 48.2 58.6 NR
Park Korea 12–19 664 <40 mg/dL 36.8 63.7 59.8
Caserta Italy 11–13 646 <40 mg/dL Males 12.4 23.3 37.7 <.05
<40 mg/dL Females 8.3 18.0 31.0 <.05
Marcus USA Mean 11.8 6358 <35 mg/dL 1.1 4.3 8.8 16.4 <.001
Kim Korea 10–18 1412 <35 mg/dL 1998 KHANES 2.5 8.1 9.2 <.05
1158 2001 KHANES 4.9 8.7 14.4 <.05
Botton France 8–17 452 <0.9 mmol/L 0.5 13 <0.001

SKINNER et al
 had to include 1 or more of: lipids, Data Synthesis and Analysis

NHANES 1999–2002
endocrinology
Population Info

blood pressure, liver function, Our primary method of data

glucose metabolism, obstructive
patients
synthesis is narrative. To allow
Pediatric

sleep apnea, asthma, or depression. broad inclusion, we did not limit to

specific designs or measures that
See the other technical report for a
would facilitate meta-analysis. We
Weight Definitions

detailed description of KQ1 report on studies in each group,

inclusion criteria.3 based on their type and design, and
we report findings for outcomes
Review Process other than BMI.
We used Covidence (Melbourne,
<.05 both

Australia) to manage the review

RESULTS
<.001
<.001
P

process. Covidence is a program for A total of 15 988 studies were

online collaboration and screened in the title and abstract
Class III

management of systematic reviews. stage. Of these, 1642 were given a

All abstracts were reviewed by 2 full-text review. Excluded studies
NR, not reported; NS, not significant; NHANES, National Health and Nutrition Examination Survey; KNHANES, Korean National Health and Nutrition Examination Survey.

(n 5 1260) were most commonly

Class II

independent reviewers for inclusion

in full-text review. Articles were not original research, did not
reviewed by 2 reviewers, with compare comorbidities by obesity
Class I

(KQ2), or were not health-care

36.21
28.1
44.3

25.6

conflicts discussed and resolved.

system based (KQ1). See Fig 1 for
Articles excluded at this stage were
the complete PRISMA diagram. Of
Overweight

assigned an exclusion reason, with a

31.81

the 382 studies included, 215 were

12.7

hierarchy as shown in Appendix 4.

intervention studies and 167 were
Data Extraction and Quality Assessment comorbidity studies. This paper
Healthy

11.04

focuses on the 167 comorbidity

3.8
6.5

5.6

All articles deemed relevant for full

studies.
text inclusion were categorized into
8.5%
Total

different data extraction strategies. Lipids

We did not include a specific quality HDL Cholesterol
Subgroup (eg, M/F)

assessment for the comorbidity

studies. A total of 39 studies examined the
prevalence of abnormal high-density
Females

8–11 y

lipoprotein (HDL),4–42 whereas 49

Males

KQ2 (Comorbidity Studies) Extraction

provided mean values for HDL.5–8,10,
All studies were extracted by 2 13,18,22,24,32,33,35,36,40–74
Table 1
Definition of Abnormal

reviewers. Extraction of these

reports the prevalence of abnormal
studies included reporting
HDL. Different countries report
prevalence of comorbidities or mean
significantly different prevalence of
NCEP values

<35 mg/dL
<40 mg/dL

values of laboratory parameters by abnormal HDL, with Korea having

weight classification. We included the highest prevalence18,30 and
healthy weight, overweight, class I Japan the lowest.42 The majority of
obesity, class II obesity, and class III
4450
1698
284

the 39 reported studies reporting

N

obesity. However, because all classes the prevalence of abnormal HDL

of obesity severity are not always were conducted in the United States
Ages (y)

12–19
6–16

8–14

reported, these classes may include (24 of 39). Abnormal HDL was
higher groups. For example, defined variably as <35 mg/dL, <40
reporting of $95th percentile would mg/dL, and <50 mg/dL or <1.0
Country

Turkey

only be considered class I obesity, mmol/L. The most consistent

TABLE 1 Continued

USA
USA

although children at higher levels findings were seen when using the
may be included. (See other definition of <40 mg/dL and when
First Author

technical report for detailed larger sample sizes were included.

Messiah
Serap

description of KQ1 extraction There was consistency of an inverse

Pan

procedures.) dose-response relationship, with

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TABLE 2 Mean HDL (n 5 49)
Subgroup Weight
First Author Country Ages (y) N Units (eg, M/F) Total Healthy Overweight Class I Class II Class III P value Notes Definitions Population Info

Kollias Greece 6–13 780 mg/dL 61.3 58.3 51.9 <.01

Friedland Israel 6–17 142 mg/dL 37.6 44.0 45.7 NS 89 OB were
treatment-
seeking
Davis USA 7–18 211 mg/dL 52 43 43 <.005 Rural Georgia
(160 for lipids)
Bonet Spain Mean 10.7 101 mmol/L 1.7 1.3 <.05 Patients were all
white
Bell Australia 6–13 283 mmol/L 1.62 1.44 1.21 <.001
Baer USA 12–22 173 mg/dL 47.8 59.3 48.0 44.6 .01 Females with PCOS
Aylanc Turkey Mean 13.5 88 mg/dL 53.5 52.9 .870
Bindler USA 11–14 151 mg/dL 48.26 40.59 <.001
Akinci Turkey 6–17 41 mmol/L 1.49 1.35 .087 HW: 25th–75th
Zabarsky USA 7–20 2244 mg/dL 50 43 43 41 <.001 IV 5 41 Includes class IV
Valerio Italy 3–16 150 mg/dL Children 51.8 53.2 NS
Adolescents 50.9 46.9 NS
Valentini Italy 5–18 84 mg/dL 51.12 47.66 .047 Patients with
Down
syndrome
Watts Australia 6–13 148 mmol/L 1.6 1.4 1.2 <.05 Assume CDC
Turchiano USA 14–18 y 1185 mg/dL 52.5 48.4 43.4 <.05 Patients of urban
minoritized
groups

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Simsek Turkey Mean 10.8 115 mg/dL 52.5 47 <.001
Salawi Canada 6–19 345 mmol/L 1.1 1 <.001 Referred to
pediatric
weight
management
program
Puri USA 10–18 198 mg/dL 66 48 <.001 General pediatrics
and
endocrinology
patients
Propst USA Mean 12.7 1111 mg/dL 44.9 43.1 .0334 Endocrinology and
pediatric
weight
management
program
patients
Rank Germany 6–19 463 mg/dL Males 55.1 44.2 <.001
mg/dL Females 53.1 47.0 <.001
Raman USA 9–13 121 mg/dL 62.2 51.9 <.001 African American
children

SKINNER et al
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TABLE 2 Continued
Subgroup Weight
First Author Country Ages (y) N Units (eg, M/F) Total Healthy Overweight Class I Class II Class III P value Notes Definitions Population Info

Perichart-Perera Mexico 9–12 88 mg/dL 29.64 27.13 29.06 NS

Perez USA (Puerto Rico) 12–18 101 mg/dL 49.0 39.0 <.001
Nystrom Spain 8–11 1247 mg/dL 62.3 56.9 51.4 47.4 Severe obesity
>99.8th
Nascimento Portugal 5–18 181 mmol/L 1.25 1.09 <.001 148 obese
patients, 33
controls
Olza Spain 6–12 446 mg/dL Males 66.96 53.78 <.001
mg/dL Females 64.13 49.25 <.001
Marcus USA Mean 11.2 1305 mg/dL 47.1 43.8 <.0001
Yoshinaga Japan 6–12 471 mg/dL Males 56 54
mg/dL Females 54 52
Venegas USA (Puerto Rico) 12–16 352 mg/dL 44.0 42.0 54.0 .4178

PEDIATRICS Volume 151, number 2, February 2023

Maximova Canada 6–19 2087 mmol/L 6–11 y 1.4 1.3 NR
12–19 y 1.3 1.2 NR
Manios Turkey 12–13 510 mg/dL Males 57.0 59.0 NS
Females 58.5 53.1 <.05
Sur Turkey 12–13 1044 mmol/L Males 1.42 1.36 NS
Females 1.40 1.30 <.05
Buchan UK 5–12 223 mmol/L 1.50 1.35 .008
Bocca Netherlands 3–5 75 mmol/L 1.28 1.30 1.27 NS
Bindler USA Mean 12.5 150 mg/dL 48.09 40.54 <.001
Garces Spain 6–8 1048 mg/dL Males 60.1 52.5 <.001

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Females 58.5 54.8 .05
Cizmecioglu Turkey 10–19 310 mg/dL 45 44 42 NS
Norris USA Mean 13.5 225 mg/dL 49.5 42.7 39.8 <.0001
Kim Korea 10–18 1412 mg/dL Males 1998 KNHANES 54.0 46.6 47.6 <.0001
Females 1998 KNHANES 54.7 48.6 46.2 <.0001
1158 Males 2001 KNHANES 46.5 45.5 42.2 .011
Females 2001 KNHANES 50.2 47.0 45.8 .003
Botton France 8–17 452 mmol/L Males 1.55 1.58 1.29 <.01
Females 1.55 1.58 1.40 <.01
Serap Turkey 6–16 284 mg/dL Males 51.6 40.4 <.05 Endocrinology
patients
Females 48.6 38.0 <.05
Craig UK 4–18 1944 mmol/L 4–10 y males 1.37 1.21 .005
4–10 y females 1.30 1.21 .085
11–18 y males 1.23 1.08 .001
11–18 y females 1.32 1.09 <.001
Valery Australia 5–17 158 mmol/L No 1.23 1.18 .449 Indigenous youth
Avnieli Velfer Israel 2–18 1027 mg/dL Males 49 42 0.01 OB 95th, Obesity clinic
SO 120%/95th patients
Females 45 45 .01 OB 95th, Obesity clinic
SO 120%/95th patients

7
 increasing weight category

clinic patients
Population Info

Pediatric weight
management

management

management
associated with lower HDL. Few

Steatohepatitis
population-

population-
School based
program

clinic 1

clinic 1
patients
OW 5 85th–97th %ile, Community

OW 5 85th–97th %ile, Community

studies provided detailed

based

based

Schools
Schools
Weight

Weight
information by obesity class, so less
could be concluded when examining
the prevalence of abnormal HDL

OW: 90th–99th,

OW: 90th–99th,
within samples of increasing
Definitions
Weight

OB: >99th

OB: >99th
severity of obesity status. In general,
OB > 97

OB > 97

HW, healthy weight; KNHANES, Korean National Health and Nutrition Examination Survey; NR, not reported; NS, not significant; OB, obese; OW, overweight; PCOS, polycystic ovary syndrome; SO, severe obesity.
P value includes HW: <90th,

P value includes HW: <90th,

overall prevalence of abnormal HDL
increases from about 10% to 40%
when children’s weight category
differences

differences
was healthy weight versus obesity.
Notes

by sex

by sex
The prevalence varied by age, with
younger ages associated with lower
prevalence of abnormal HDL. For
Total Healthy Overweight Class I Class II Class III P value

.047
<.001

<.001

.072

<.001
.709
example, in a study of 9- to 13-year-
NR

NS
<.05

olds, those who had healthy weight

1.08

had a prevalence of abnormal HDL

38.5

of 10.2%, whereas those with

obesity had a prevalence of
1.11

38

abnormal HDL of 32.5%.15 In a

study of 14- to 18-year-olds, those
1.15

1.07

1.15

1.14
1.14

38

who had healthy weight had a

prevalence of abnormal HDL of
1.18

1.27

1.3
54.4
1.3

58.3
67.7

13.2% and those with obesity had a

44

prevalence of abnormal HDL of

38.9%.40 When studies report larger
1.26

1.30

1.5
58.9
1.5

65.2
68.5

age ranges, it is difficult to see these

distinctions, and the mean
1.12

64.0
68.4

prevalence might be obfuscating the

differences in prevalence at the
younger versus older ages. A few
Subgroup
(eg, M/F)

studies stratified their findings by

biological sex. In 2 US-based studies,
See males Females

Females

Females
Males

Males

Males

there appears to be a higher

prevalence of abnormal HDL in
Units

mmol/L

mmol/L

mmol/L

female children of both healthy

mg/dL

mg/dL

mg/dL
mg/dL

weight and overweight, but the

prevalence is similar regardless of
sex once children are categorized as
1332

3978

1679
847

120

767
N

obese.12,20 Studies conducted in

other countries also report
differences by biological sex, but not
Median 12

Mean 13
Ages (y)

12–13

12–18
5–17

5–19

always in the same direction or to

the same degree.9,19,35,42 Caution
should be used in interpreting these
Country

results when small sample sizes

Denmark

were used.
Canada

Canada

Japan
Korea

USA
TABLE 2 Continued

Table 2 reports the mean HDL

values. Mean HDL values
Hadjiyannakis

Kloppenberg
First Author

corroborate the findings regarding

Sougawa
Higgins

the prevalence of abnormal HDL,

Seth
Kim

highlighting that age, sex, and

8 SKINNER et al
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TABLE 3 Prevalence of Abnormal LDL (n 5 26)
Definition of Subgroup
First Author Country Ages (y) N Abnormal (eg, M/F) Total Healthy Overweight Class I Class II Class III P Weight Definitions Population Info
Ice USA Mean 10.8 23263 >130 mg/dL 8.7 5.9 10.2 13.3 11.4 <.05, normal
to others
Ice USA 9–13 29286 >130 mg/dL 6.3 10.9 13.2 <.01 Appalachian
population school-
aged children
Davis USA 7–18 211 >110 mg/dL 19 25 19 NS
(160 for lipids)
Bell Australia 6–13 283 >2.9 mmol/L 35.1 41.3 42.1 .584
Bindler USA 11–14 151 >110 mg/dL 26.4 31.7 .515
NCHS USA 12–19 3125 >130 mg/dL 7.6 5.8 8.4 14.2 Obese <.05 1999–2006
Skinner USA 6–17 NR >130 mg/dL 8.7 7.7 10.9 11.4 <.05 NHANES 2001–2002
Simsek Turkey Mean 10.8 115 >130 mg/dL 0 10.7 .049

PEDIATRICS Volume 151, number 2, February 2023

Salvatore USA 3–18 101 >110 mg/dL 55.6 44.4 23.3 .041 Class 1: >100% Pediatric
to 120%; class gastroenterology
II/III: standard patients
O’Hara USA 3–19 382 $110 mg/dL 29 29 27 34 26 NS Rural pediatric
weight
management
program patients
Marcus USA Mean 11.2 1305 >130 mg/dL 6.6 6.3 .8243
Michalsky USA Mean 17 242 >130 mg/dL 6.2 11.7 8.3 NS 1: BMI 30–50, 2: Bariatric surgery
BMI 50–60, 3: patients
BMI >60

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Skinner USA 3–19 8579 $130 mg/dL 8.16 12.08 11.63 10.46 .11
Maximova Canada 6–19 2087 >75th percentile 6-11 y 21.3 35.5 NR
12-19 y 22.7 30.9 NR
Li USA 3–19 20905 >130 mg/dL 6.08 8.66 11.15 12.96 <.05
Park Korea 10–19 1554 >130 mg/dL 5.0 6.1 15.3 <.05 obesity
Caserta Italy 11–13 646 >130 mg/dL Males 3.4 7.8 17.0 <.05 obesity
Females 6.5 6.7 3.4 NS
Marcus USA Mean 11.8 6358 >110 mg/dL 10.9 18.2 21.7 20.1 <.001
Kim Korea 10–18 1412 >130 mg/dL 1998 KNHANES 4.3 8.1 27.6 <.05
1158 2001 KNHANES 6.5 11.5 15.8 <.05
Botton France 8–17 452 >3.4 mmol/L Yes 5.9 5.1 1.0
Serap Turkey 6–16 284 NCEP values Males 0 3.4 <.001 Pediatric
endocrinology
patients
Females 4.3 4.1 <.001
Lambert Canada 9–16 3613 >2.6 mmol/L Males 18.0 28.3 37.8 <.0001
Females 31.2 42.9 40.5 .014
Valery Australia 5–17 158 >3.4 mmol/L No 15 16 .891 Indigenous youth
Avnieli Velfer Israel 2–18 1027 >95th percentile Males NS OB 95th, SO Obesity clinic
120%/95th patients
Females NS OB 95th, SO Obesity clinic
120%/95th patients

9
 country affect the findings of mean there was not a significant

program patients
HDL values. Also apparent is the difference at any weight
Population Info
Adolescent clinic

Adolescent clinic

Pediatric weight
management
patients importance of sample size to lead to classification.5,9,12,19,35 Similarly to
patients
a stable mean value. Several of these the LDL prevalence studies, the
studies reported mean values for most evidence for mean LDL in
large age ranges. In almost all of populations includes children of
these studies, mean HDL decreases school age and older (Table 4). Only
Weight Definitions

as weight category increases, 1 of the identified studies

validating the association between exclusively included children
the 2. younger than 5 years46; therefore, it
is difficult to draw conclusions in
LDL Cholesterol this younger age group. Sample size
A total of 26 studies examined the of the reported studies ranged from
NR

41 to 2244. Several, but not all,

P

prevalence of abnormal low-density

.135

.612

lipoprotein (LDL),4–10,12,13,15,16, studies reported male and female

18,19,21–24,26,28,31,34–38,41 LDL levels separately. Mean LDL
whereas 41
Total Healthy Overweight Class I Class II Class III

provided mean values for LDL.5–8, was reported in some cases in

7

10,13,18,22,24,33,35,36,40,41,43–46,50–52, mg/dL and in other cases as mmol/L.

54–67,69,70,72–75 Across all studies, mean LDL tended
Table 3 reports the
to increase with increasing BMI;
11

prevalence of abnormal LDL.

Approximately half (n 5 13) of the however, only the difference between
86.4

studies evaluated children 9 years healthy weight and obese consistently

89

11

or older, a time point associated achieved statistical significance.

with physiologic increases in LDL In 1 Korean study that evaluated
96.5

86.4

cholesterol.76 The remaining studies mean LDL in 1998 and again in 2001,
included children as young as 3 and secular increases in mean LDL were
up to 19 years of age. Sample size also observed.17 Although in some
varied from 101 to 29 286; 13 of cases, females have higher mean LDL
23 studies reported sample sizes of than males at matched age and BMI,
10

1000 or greater. One challenge in this difference was inconsistent and

interpreting these data are the did not achieve statistical significance.
Subgroup
(eg, M/F)

variation in definition of and However, the difference between

Females

reported units for abnormal LDL. mean LDL when comparing healthy
Males

Authors defined abnormal LDL as weight and obesity was more

>110 mg/dL or >2.6 mmol/L pronounced in males than females. It
through >130 mg/dL or >3.4 mmol/ is interesting to note that in all
Definition of
Abnormal

>3.4 mmol/L
>130 mg/dL

L. In 1 instance, authors used >75th studies, even in the highest BMI

percentile of National Cholesterol subcategories, mean LDL values did
Education Program (NCEP) not exceed commonly accepted
NR, not reported; NS, not significant; OB, obese; SO, severe obesity.

standards.24 In nearly all the definitions for normal.

studies, abnormal LDL was more
363

847

Triglycerides
N

prevalent in children with

increasing BMI, and when A total of 38 studies examined the
comparing healthy weight with prevalence of abnormal triglycerides
(TG),4–26,28–32,34–42 whereas
Ages (y)

obesity, this difference consistently

11–18

5–17

achieved statistical significance. The 48 provided mean values for TG.5–8,

10,13,18,22,24,32,35,36,40–60,62–75,77
majority of studies did not include a Table
Country

significant number of children in 5 reports the prevalence of

Hadjiyannakis Canada

each obesity classification; abnormal TG. About half of the

USA
TABLE 3 Continued

therefore, it is difficult to conclude 38 reported studies were conducted

whether abnormal LDL is more in the United States (20 of 38).
First Author

common by obesity classification. Country comparisons are not

Gunes

Among the 3 studies that reported possible given the variety of cutoff
male and female LDL separately, values employed. However, there is

10 SKINNER et al
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by guest
by guest
TABLE 4 Mean LDL (n 5 41)
Subgroup
First Author Country Ages (y) N Units (eg, M/F) Total Healthy Overweight Class I Class II Class III P Notes Weight Definitions Population Info

Kollias Greece 6–13 780 mg/dL 90.6 93.4 95.6 NS

Friedland Israel 6–17 142 mg/dL 90.2 103.3 104.6 <.05
Davis USA 7–18 211 mg/dL 87 91 93 NS Rural Georgia
(160 for lipids)
Bell Australia 6–13 283 mmol/L 2.56 2.48 2.84 .065
Baer USA 12–22 173 mg/dL 102 92.9 101.1 104.9 .59 Females with PCOS
Aylanc Turkey Mean 13.5 88 mg/dL 69.51 109.4 <.001
Bindler USA 11–14 151 mg/dL 96.65 96.44 .961
Akinci Turkey 6–17 41 mmol/L 2.09 2.19 .322 HW: 25th–75th
Zabarsky USA 7–20 2244 mg/dL 90 92 94 95 .86 IV 5 90 Includes class IV
Valentini Italy 5–18 84 mg/dL 96.25 110.77 .013 Patients with
Down
syndrome

PEDIATRICS Volume 151, number 2, February 2023

Watts Australia 6–13 148 mmol/L 2.5 2.6 2.7 NS
Turchiano USA 14–18 1185 mg/dL 85.4 92.0 98.0 <.05 Patients of urban
minoritized
groups
Simsek Turkey Mean 10.8 115 mg/dL 66.3 92 <.001
Salawi Canada 6–19 345 mmol/L 2.7 2.6 .1 Pediatric weight
management
program
patients
Puri USA 10–18 198 mg/dL 80 94 NS Minority youth

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Propst USA Mean 12.7 1111 mg/dL 103.2 102.1 .6520 SO > 99th Endocrinology and
pediatric
weight
management
program
patients
Rank Germany 6–19 463 mg/dL Males 98.8 110.0 .026
Females 97.6 102.6 .229
Raman USA 9–13 121 mg/dL 100.1 97.9 .732 African American
children
Perichart-Perera Mexico 9–12 88 mg/dL 114.04 101.88 112.21 NS
Nystrom Spain 8–11 1247 mg/dL 94.7 100.8 101.8 101.8 SO > 99.8th
Nascimento Portugal 5–18 181 mmol/L 2.31 2.63 .001
Olza Spain 6–12 446 mg/dL Males 93.82 94.58 .835
Females 94.44 98.07 .282
Marcus USA Mean 11.2 1305 mg/dL 91.7 92.5 .5745
Venegas USA 12–16 352 mg/dL 73.5 65.0 75.5 .3367
(Puerto Rico)
Maximova Canada 6–19 2087 mmol/L 6–11 y 2.2 2.6 NR
12–19 y 2.2 2.5 NR

11
by guest
12
TABLE 4 Continued
Subgroup
First Author Country Ages (y) N Units (eg, M/F) Total Healthy Overweight Class I Class II Class III P Notes Weight Definitions Population Info

Manios Turkey 12–13 510 mg/dL Males 77.6 95.3 <.01

Females 87.1 88.4 NS
Sur Turkey 12–13 1044 mmol/L Males 2.39 2.71 <.001
Females 2.57 2.64 NS
Bocca Netherlands 3–5 75 mmol/L No 2.48 2.41 2.52 NS
Bindler US Mean 12.5 150 mg/dL 96.91 96.64 .95
Garces Spain 6–8 1048 mg/dL Males 108.8 112.5 .42
Females 111.5 104.3 .07
Norris USA Mean 13.5 225 mg/dL 78.9 87.2 99.0 <.001
Kim Korea 10–18 1412 mg/dL 1998 Males 84.6 94.2 105.5 <.0001
1998 Females 93.0 98.0 103.2 .026
1158 2001 Males 91.1 100.4 101.0 .001
2001 Females 97.1 104.6 107.5 .004
Botton France 8–17 452 mmol/L Males 2.16 2.14 2.36 NS
Females 2.36 2.34 2.51 NS
Serap Turkey 6–16 284 mg/dL Males 79.4 101.1 <.001 Endocrinology
patients
Females 78.6 99.4 <.001
Craig UK 4–18 1944 mmol/L 4–10 y males 2.81 3.07 .059
4–10 y females 3.02 3.15 0.440
11–18 y males 2.70 2.81 .308
11–18 y females 2.83 2.97 .148
Valery Australia 5–17 158 mmol/L 2.77 2.87 .341 Indigenous youth

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Avnieli Velfer Israel 2–18 1027 mg/dL Males 100 100 .26 OB 95th, SO 120%/ Obesity clinic
95th patients
mg/dL Females 96 102 .18 OB 95th, SO 120%/ Obesity clinic
95th patients
Hadjiyannakis Canada 5–17 847 mmol/L 2.42 2.41 2.42 2.44 NR Pediatric weight
management
program
patients
Kim Korea 12–13 120 mg/dL 80.6 92.6 .009 School based
Kloppenberg Denmark Median 12 3978 mmol/L Males 1.9 2.15 2.26 <.001 P value includes HW: <90th, OW: Weight
differences by sex 90th–99th, OB: management
>99th clinic 1
population-
based
Females 2.0 2.2 2.3 <.001 P value includes HW: <90th, OW: Weight
differences by sex 90th–99th, OB: management
>99th clinic 1
population-
based
Seth USA Mean 13 767 mg/dL 151 195.5 207 178 .78 Steatohepatitis
clinic patients
HW, healthy weight; KNHANES, Korean National Health and Nutrition Examination Survey; NR, not reported; NS, not significant; OB, obese; OW, overweight; PCOS, polycystic ovary syndrome; SO, severe obesity.

SKINNER et al
by guest
TABLE 5 Prevalence of Abnormal Triglycerides (n 5 38)
Subgroup
First Author Country Ages (y) N Definition of Abnormal (eg, M/F) Total Healthy Overweight Class I Class II Class III P Weight definitions Population Info

Kim Korea 10–19 931 >110 mg/dL 22.1 17.1 33.7 46.1 <.0001
Halley Castillo Mexico 7–24 1366 >100 mg/dL 33% 64.1% <.000
Ice USA Mean 10.8 23263 >150 mg/dL 12.2 4.4 12.4 25.0 31.3 <.05
Ice USA 9–13 29286 >110 mg/dL 14.2 29.8 49.1 <.01 Appalachian population
school-aged children
Duncan USA 12–19 991 >110 mg/dL 17.1 27.8 45.5 NHANES 1999–2000
Davis USA 7–18 211 >150 mg/dL 11 9 18 NS Rural Georgia
(160 for lipids)
Bell Australia 6–13 283 >1.6 mmol/L 9.9 11.3 26.3 .104
Bindler USA 11–14 151 >150 mg/dL 6.4 14.6 .107
NCHS USA 12–19 3125 >150 mg/dL 10.2 5.9 13.8 24.1 <.05 1999–2006
Turchiano USA 14–18 1185 >110 mg/dL 6.7 13.2 23.3 <.001 Patients of urban

PEDIATRICS Volume 151, number 2, February 2023

minoritized groups
Skinner USA 6–17 NR >200 mg/dL 3.5 2.1 6.1 6.7 <.05 NHANES 2001–2002
Simsek Turkey Mean 10.8 115 >150 mg/dL 2.5 61.3 <.001
Salvatore USA 3–18 101 >130 mg/dL 22.2 42.9 38.7 .236 Class 1: >100% to Pediatric
120%; class II/III: gastroenterology
standard patients
Perez USA 12–18 101 $100 mg/dL 18.9 41.7 .012
(Puerto Rico)
O’Hara USA 3–19 382 >75 mg/dL 0–9 y; 72 63 55 74 76 NS Rural pediatric weight
>90 mg/dL 10–19 y management
program patients

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Marcus USA Mean 11.2 1305 >130 mg/dL 26.6 34.3 .0037
Michalsky USA 13–19 242 $130 mg/dL 40.3 41.6 40.3 37.5 .90 1: BMI 30–50, 2: BMI Bariatric surgery
50–60, 3: BMI patients
>60
Yoshinaga Japan 6–12 471 >120 mg/dL Males 20.5 33.5
Females 26.7 40.2
Skinner USA 3–19 8579 $150 mg/dL No 12.16 20.35 18.81 28.82 <.001 NHANES 1999–2012
Maximova Canada 6–19 2087 >75th percentile 6–11 y 20.3 39.7 NR
12–19 y 20.6 31.7 NR
Li USA 6–19 20905 $130 mg/dL 13.67 9.71 16.36 25.25 29.77 <.05
Park Korea 10–19 1554 >150 mg/dL 6.0 21.2 30.5 <.05 2007–2008 KNHANES
Laurson USA 12–18.9 3385 Joliffe standards Males 7.6 17.9 31.4 NR NHANES
Females 8.4 10.7 18.3 NR
Park Korea 12–19 664 $150 mg/dL 4.8 11.6 24.3 Only reporting Korea,
US is NHANES
Caserta Italy 11–13 646 >150 mg/dL Males 1.4 7.8 5.66 <.05 OW
Females 1.2 5.6 13.8 <.05

13
 consistency of a dose-response

Community recruitment
Pediatric endocrinology

Obesity clinic patients

Obesity clinic patients

program patients
relationship with increasing weight
Population Info

NHANES 1999–2002

Indigenous youth

Adolescent clinic

Adolescent clinic

Pediatric weight
management
category associated with higher TG
prevalence in most settings studied.

patients

patients

patients
Few studies provide detailed
information broken down by obesity
class, so less can be concluded when
Weight definitions

OB 95th, SO 120%/

OB 95th, SO 120%/
examining the prevalence of
abnormal TG and increasing severity
of obesity status. When studies

95th

95th
report larger age ranges, it is
difficult to see these distinctions,
<.05 OB

<.05 OB

<.0001
<.001

<.001

<.001

.002
.134
.001

.223

.247
NS

NS
and the mean prevalence might be
<.05
<.05

<.05
P

NR
masking any potential differences in
Class II Class III

prevalence at the younger versus

0.08
44.3

39
older ages. A few studies stratified
their findings by gender, but the
58.5

40
pattern of high TG prevalence was
12-14: 52.40

not always in the same direction or

40.7
38.2
35.1

24.7
18.5
22.2
48.9

17.5
11.8

70.4

79.8
Class I

7
27

45

30 to the same degree. Caution should

KNHANES, Korean National Health and Nutrition Examination Survey; NR, not reported; NS, not significant; OB, obese; OW, overweight; SO, severe obesity.
be used in interpreting these results
when small sample sizes were used.
12–14: 17.50 12–14: 15.47
Overweight

25.4
23.1
29.8

12.0
22.6
24.7

11.7
10.4

58.6

72.4
10

20

Table 6 reports the mean TG values.

The sample sizes of the studies
11.5
10.4
15.6

19.2
3.7
1.9

8.6
7.2
9.6

1.0
3.7

presented vary from 41 to 3978. In

Healthy

10
7

almost all of these studies, mean TG

value increases as weight category
22.20%
Total

increases, validating the association

36

between the 2. In the majority of

1998 KNHANES
2001 KNHANES

studies, the mean TG value is <130

Subgroup
(eg, M/F)

mg/dL.
Females

Females

Females

Females

Females
Males

Males

Males

Males

Males
No
No

No

Total Cholesterol
Definition of Abnormal

A total of 23 studies examined the

>95th percentile

prevalence of abnormal total

>1.5 mmol/L

>1.7 mmol/L

>1.5 mmol/L
>110 mg/dL
>130 mg/dL

>150 mg/dL

>110 mg/dL
>110 mg/dL

>130 mg/dL

>125 mg/dL
NCEP values

cholesterol,6–10,12,13,15,16,18,19,21–24,
27,28,34–38,78
whereas 42 provided
NR

mean values for total

cholesterol.5–8,10,13,18,22,
24,32,33,35,36,43–47,49–55,57–59,
452
284

158

363

847
6358
1412
1158

1819

4450
1698
3613

1027

62
N

61–66,69–75,79
In large (>20 000)
population based studies, the
Mean 11.8
Ages (y)

prevalence of abnormal cholesterol

10–18

12–19

11–18

12–17
8–17
6–16

6–13

8–14
9–16

5–17
2–18

5–17

(>200 mg/dL) in children of normal

weight ranged from 7.5% to 8.3%,
in children with overweight ranged
Country

from 10.0% to 12.7%, and in

Australia
Canada

Canada
Del- Rio-Navarro Mexico
France
Turkey
Korea

Israel

children with obesity ranged from

TABLE 5 Continued

USA

USA
USA

USA

USA

14.5% to 16.9% (Table 7).15,16,21

There was a significant difference in
Hadjiyannakis
Avnieli Velfer
First Author

prevalence of elevated cholesterol

Stolzman
Lambert
Messiah
Marcus

Botton

Valery

Gunes
Serap

between children of normal weight

Kim

Pan

and children with overweight and

14 SKINNER et al
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by guest
by guest
TABLE 6 Mean Triglycerides (n 5 48)
Subgroup
First Author Country Ages (y) N Units (eg, M/F) Total Healthy Overweight Class I Class II Class III P Notes Weight definitions Population Info

Kollias Greece 6–13 780 mg/dL 71.7 80.9 93.8 <.01

Friedland Israel 6–17 142 mg/dL 94.3 89.6 127.2 <.05
Davis USA 7–18 211 mg/dL 88 89 111 NS Rural Georgia
(160 for lipids)
Bonet Spain Mean 10.7 101 mM 0.4 0.8 <.001
Bell Australia 6–13 283 mmol/L 0.80 0.91 1.25 <.001
Baer USA 12–22 173 mg/dL 120.3 94.6 143.0 121.7 .22 Females with PCOS
Aylanc Turkey Mean 13.5 88 mg/dL 67.1 119 <.001
Bindler USA 11–14 151 mg/dL 87.14 111.54 .002
Akinci Turkey 6–17 41 mmol/L 0.72 0.82 .411 HW: 25th–75th
Zabarsky USA 7–20 2244 mg/dL 96 117 113 114 .007 IV 5 102 Includes class IV
Valerio Italy 3–16 150 mg/dL Children 59.7 80.6 .005

PEDIATRICS Volume 151, number 2, February 2023

Adolescents 58.5 80.4 0.015
Valentini Italy 5–18 84 mg/dL 71.05 97.16 .014 Patients with
Down
syndrome
Watts Australia 6–13 148 mmol/L 0.8 0.9 1.1 <.05
Turchiano USA 14–18 1185 mg/dL 66.2 73.4 90.6 <.05 HW versus OB Patients of urban
minoritized
groups
Simsek Turkey Mean 10.8 115 mg/dL 78.5 160 < .001
Salawi Canada 6–19 345 mmol/L 1.4 1.5 .2 Patients referred
to pediatric

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weight
management
program
Puri USA 10–18 198 mg/dL 78 113 <.001 Youth of
minoritized
groups
Rank Germany 6–19 463 mg/dL Males 53.7 70.9 <.001
Females 59.8 77.0 <.001
Raman USA 9–13 121 mg/dL 59.5 75.1 .018 African American
children
Perichart-Perera Mexico 9–12 88 mg/dL 106.12 156.22 181.25 .002 HW versus OB
Perez USA 12–18 101 mg/dL 83.0 94.0 .022
(Puerto Rico)
Nystrom Spain 8–11 1247 mg/dL 60.5 74.6 92.2 111.7 SO > 99.8th
Nascimento Portugal 5–18 181 mmol/L 0.72 0.86 .017
Marcus USA Mean 11.2 1305 mg/dL 108.8 125.9 <.0001
Yoshinaga Japan 6–12 471 mg/dL Males 93 116
Females 100 116
Venegas USA 12–16 352 mg/dL 58.0 57.0 58.0 .6971
(Puerto Rico)

15
by guest
16
TABLE 6 Continued
Subgroup
First Author Country Ages (y) N Units (eg, M/F) Total Healthy Overweight Class I Class II Class III P Notes Weight definitions Population Info

Maximova Canada 6–19 2087 mmol/L 6–11 y 0.7 1.0 NR

12–19 y 0.9 1.1 NR
Manios Turkey 12–13 510 mg/dL Males 82.1 126.6 <.001
Females 93.4 109.7
Sur Turkey 12–13 1044 mmol/L Males 0.93 1.31 <.001
Females 1.07 1.24 <.05
Buchan UK 5–12 223 mmol/L 0.75 0.87 .032
Bocca Netherlands 3–5 75 mmol/L 0.78 0.70 0.83 NS
Bindler USA Mean 12.5 150 mg/dL 87.24 112.18 .002
Garces Spain 6–8 1048 mg/dL Males 69.9 88.8 <.001
Females 75.1 83.5 .03
Cizmecioglu Turkey 10–19 310 mg/dL 69 84 104 <.001
Norris USA Mean 13.5 225 mg/dL 72.0 94.1 121.9 <.0001
Kim Korea 10–18 1412 mg/dL 1998 Males 77.7 100.4 117.8 <.0001
1998 Females 88.6 100.0 114.2 <.0001
1158 2001 Males 89.7 125.4 138.5 <.0001
2001 Females 91.4 106.7 129.3 <.0001
Botton France 8–17 452 mmol/L Males 0.662 0.64 0.93 <0.001
Females 0.735 0.72 0.83 NS
Serap Turkey 6–16 284 mg/dL Males 73.1 101.8 <.05 Endocrinology
patients
Females 73.9 99.8 <.001
Craig UK 4–18 1944 mmol/L 4–10 y males 0.72 0.98 <.001

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4–10 y females 0.86 1.03 .072
11–18 y males 0.96 1.28 .035
11–18 y females 0.96 1.21 .033
Del- Rio-Navarro Mexico 6–13 1819 mg/dL Males 84.9 94.6 108.7 <.05
Females 88.7 106.8 108.9 <.05
Valery Australia 5–17 158 mmol/L Median 5 0.80 Median 5 0.90 .070 Indigenous youth
Avnieli Velfer Israel 2–18 1027 mg/dL Males 120 120 .93 OB 95th, SO 120%/ Obesity clinic
95th patients
Females 126 126 .01 OB 95th, SO 120%/ Obesity clinic
95th patients
Hadjiyannakis Canada 5–17 847 mmol/L 1.24 1.15 1.32 1.31 NR Pediatric weight
management
Higgins Canada 5–19 1332 mmol/L Males 1.23 1.39 1.74 <.05 OW 5 85th–97th Community
%ile, OB >97
Females 1.23 0.45 1.56 <.05 OW 5 85th–97th Community
%ile, OB > 97
Kim Korea 12–13 120 mg/dL 68.5 94.0 .008 School based

SKINNER et al
 obesity. In 6 medium-sized studies

clinic patients
Population Info

of children (n 5 2000–9000),
management

management

Steatohepatitis
population-

population-
clinic 1

clinic 1
2 studies did not provide statistical

based

based

Schools
Schools
testing. In the remaining 4 studies,
Weight

Weight
2 studies used >200 mg/dL as a
cutoff for abnormal cholesterol, and
Weight definitions

90th–99th, OB:

90th–99th, OB: 2 studies used >170 mg/dL and

HW: <90th, OW:

HW: <90th, OW:

>4.4 mmol/L. One study showed a

>99th

>99th

significant difference in the

prevalence of elevated cholesterol
differences by sex

differences by sex

among children of normal weight

P value includes

P value includes

and children with obesity; a second

Notes

study was significant only for males.

One study did not report results for
normal weight children. The range
of prevalence of elevated total
cholesterol for children with healthy
P

weight was 16.9% to 31%, for

<.001

<.001

.072

<.001
.236

children who were overweight was

10.0% to 34.5%, and for children
Class I Class II Class III

with obesity was 14.3% to 35.5%.

127

There were 16 studies of children

including 100 to 1412 children.
135

HW, healthy weight; NR, not reported; NS, not significant; OB, obese; OW, overweight; PCOS, polycystic ovary syndrome; SO, severe obesity.

Three studies did not provide

0.89

1.01

133

statistical testing. Of the remaining

13 studies, 6 used 200 mg/dL as a
2.2

0.8

81.4
62.5
Overweight

102

cutoff for abnormal values, 4 used

170 mg/dL, and 2 used NCEP
guidelines. Five studies did not
include children with healthy
Healthy

0.5

0.6

55.3
58.8

weight. In the 7 studies remaining,

4 showed significant differences in
total cholesterol between children
Total

60.0
59.1

with healthy weight and children

with obesity.
Subgroup
(eg, M/F)

Females

Females

Of the 42 studies reporting mean

mmol/L Males

mg/dL Males

cholesterol levels, 3 studies did not

report statistical testing (Table 8).
Units

mg/dL

Of the remaining 39 studies, 13

reported significant differences
3978

1679
767

between mean cholesterol levels in

N

children with healthy weight and

children with obesity. One study
Median 12

Mean 13
Ages (y)

12–18

reported significant differences in

males but not females, 1 study
reported significant differences in
Country

females but not males, and a third

Denmark

reported differences in both sexes.

Japan
TABLE 6 Continued

USA

Dyslipidemia
Kloppenberg
First Author

An additional 6 studies examined

Sougawa

the prevalence of dyslipidemia.13,26,

Seth

80–83
Table 9 reports the prevalence

PEDIATRICS Volume 151, number 2, February 2023 17

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by guest
by guest
18
TABLE 7 Prevalence of Abnormal Total Cholesterol (n 5 23)
Definition of
First Author Country Ages (y) N Abnormal Subgroup Total Healthy Overweight Class I Class II Class III P Weight Definitions Population Info
Ice USA Mean 10.8 23263 >200 mg/dL 10.7 7.5 11.5 16.3 15.0 <.05 99% SO
Ice USA 9–13 (5th 29286 >200 mg/dL 8.3 12.7 16.9 <.01 Appalachian population
grade) school-aged children
Davis USA 7–18 211 (160 for >170 mg/dL 23 21 34 NR Rural Georgia
lipids)
Bell Australia 6–13 283 >4.5 mmol/L 57.9 58.8 63.2 .906
Bindler USA 11–14 151 >170 mg/dL 34.5 34.1 .963
Skinner USA 6–17 NR >200 mg/dL 9.4 7.2 12.4 15.7 <.01 NHANES 2001–2002
Simsek Turkey Mean 11 115 >200 mg/dL 0 24 <.001
Salvatore USA 3–18 101 >170 mg/dL 66.7 67.9 48.1 29.0 .012 Class 1: >100% Pediatric
to 120% gastroenterology
patients
O’Hara USA 3–19 382 $170 mg/dL 25 40 42 47 37 NR Referred to PWMP
Nguyen, D USA 6–19 NR $200 mg/dL 7.4% 6.3% 6.9% 11.6% <.05 NHANES 2011–2014
Marcus USA Mean 11.2 1305 >200 mg/dL 9.5 8.5 .5535
Skinner USA 3–19 8579 $200 mg/dL 10.02 14.27 16.19 18.59 <.001 NHANES 1999–2012
Maximova Canada 6–19 2087 >75th %ile 6–11 y 27.9 35.5 NR
12–19 y 20.4 29.2 NR
Li USA 6–19 20905 $200 mg/dL 9.38 7.62 10.02 14.47 16.53 <.05
Caserta Italy 11–13 646 >200 mg/dL Males 4.8 8.9 9.4 NR
Females 5.3 5.6 6.9 NR
Marcus USA Mean 11.8 6358 >170 mg/dL 26 31.4 35.5 34.1 <.001 SO > 99th
Kim Korea 10–18 1412 >200 mg/dL 1998 KNHANES 7.1 11.3 23.7 <.05 1998 KNHANES, 2001

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reported separately
1158 2001 KNHANES 7.3 14.4 18.6 <.05 2001 KNHANES
Botton France 8–17 452 >5.2 mmol/L 10 13 0.58 NR OW > 90th
Serap Turkey 6–16 284 NCE values Males 1.9 15.7 <.001 Pediatric endocrinology
patients
Females 6.5 7.2 <.001
Lambert Canada 9–16 3613 >4.4 mmol/L Males 16.9 29.4 31.8 <.0001
Females 31.0 34.5 30.8 .715
Hadjiyannakis Canada 5–17 847 >5.2 mmol/L 11 14 14 5 NR Pediatric weight
management program
patients
Fyfe-Johnson USA 8–17 300 >170 mg/dL 35 26 41 41 Clinic patients
Gunes USA 11–18 363 >200 mg/dL Males 84 100 .023 Adolescent clinic patients
Females 81.3 88.4 .180 Adolescent clinic patients
KNHANES, Korean National Health and Nutrition Examination Survey; NR, not reported; NS, not significant; OW, overweight; PWMP, pediatric weight management program; SO, severe obesity.

SKINNER et al
by guest
TABLE 8 Mean Total Cholesterol (n 5 42)
Weight
First Author Country Ages (y) N Units Subgroup Total Healthy Overweight Class I Class II Class III P Notes Definitions Population Info
Friedland Israel 6–17 142 mg/dL 143.3 164.1 177.6 <.05
Davis USA 7–18 211 (160 mg/dL 155 153 159 NS Rural Georgia
for lipids)
Bonet Spain Mean 10.7 101 mM 4.1 4.2 NS Patients were all
white
Bell Australia 6–13 283 mmol/L 4.55 4.62 4.64 .795
Baer USA 12–22 173 mg/dL 167.7 160.2 169.9 169.6 .63 Females with PCOS
Aylanc Turkey Mean 13.5 88 mg/dL 137.6 171.3 <.001
Bindler USA 11–14 151 mg/dL 162.25 159.39 .569
Akinci Turkey 6–17 41 mmol/L 3.94 4.03 .548 HW: 25th–75th
Zabarsky USA 7–20 2244 mg/dL 160 158 159 159 .007 IV 5 151
Valerio Italy 3–16 150 mg/dL Children 152.4 165.1 NS
Adolescents 155.6 163.3 NS
Valentini Italy 5–18 84 mg/dL 151.20 163.45 .046 Patients with Down
syndrome
Watts Australia 6–13 148 mmol/L 4.4 4.5 4.4 NS

PEDIATRICS Volume 151, number 2, February 2023

Simsek Turkey 10.8 SD: 2.03 115 mg/dL 101 175 <.001 OB > 97th
Salawi Canada 6–19 y 345 mmol/L 4.3 4.5 .2 SO > 99th Referred to
pediatric weight
management
program
patients
Puri USA 10–18 198 mg/dL 161 165 NS Youth of
minoritized
groups
Propst USA Mean 12.7 1111 mg/dL 173.8 168.9 .2631 SO > 99th Pediatric
endocrinology
patients
Rank Germany 6–19 463 mg/dL Males 154.7 161.7 .147

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Females 153.9 155.5 .679
Raman USA 9–13 121 mg/dL 177.7 165.9 .111 African American
children
Perichart-Perera Mexico 9–12 88 mg/dL 164.00 160.26 177.53 NS
Perez USA (Puerto Rico) 12–18 101 mg/dL 140.0 153.5 .011
Nascimento Portugal 5–18 181 mmol/L 4.29 4.11 .241
Olza Spain 6–12 446 mg/dL Males 173.87 163.69 .018
Females 171.02 164.87 .094
Marcus USA Mean 11.2 1305 mg/dL 160.5 161.2 .6190
McCarthy USA 11–14 199 mg/dL 163.38 176.17 188.57 <.05 OB Children of
versus HW minoritized
groups
Venegas USA (Puerto Rico) 12–16 352 mg/dL 137.0 122.0 143.0 .0516
Maximova Canada 6–19 2087 mmol/L 6–11 y 4.2 4.4 NR
12–19 y 4.0 4.2 NR
Manios Turkey 12–13 510 mg/dL Males 150.7 179.2 <.001
mg/dL Females 164.8 163.6
Sur Turkey 12–13 1044
Bocca The Netherlands 3–5 75 mmol/L 3.79 3.89 NS
Bindler USA Mean 12.5 150 mg/dL 162.44 159.67 .59
Garces Spain 6–8 1048 mg/dL Males 182.9 182.5 .92
Females 184.7 175.8 .03
Cizmecioglu USA 10–19 310 mg/dL 147 153 166 .007
Norris USA Mean 13.5 225 mg/dL 142.0 148.7 163.2 <.0001
Kim Korea 10–18 1412 mg/dL 1998 Males 154.1 160.9 176.6 <.0001
1998 Females 165.3 166.4 172.2 0.381
1158 2001 Males 155.4 171.0 169.7 <.0001
2001 Females 165.6 172.9 179.1 .002

19
 of dyslipidemia (n 5 6). The
Population Info

endocrinology
likely reason for the low number

Pediatric weight
management

management

management
population-

population-
School based
Obesity clinic

Obesity clinic
of studies in this category is the

program

clinic 1

clinic 1
patients

patients

patients

patients
Community

OW 5 85th–97th Community

based

based
Pediatric
high variance in how dyslipidemia

Weight

Weight
is defined. In 2 of these studies,
similar criteria were listed: low

%ile, OB >97th

%ile, OB >97th

OW: 90th–99th,

OW: 90th–99th,
SO 120%/95th

SO 120%/95th

OW 5 85th–97th
HDL, high LDL, and high TG.
Definitions

OB: >99th

OB: >99th
Weight

In 1 study, a total cholesterol

P value includes HW: <90th,

P value includes HW: <90th,

>200 mg/dL was also required
OB 95th,

OB 95th, for the diagnosis of dyslipidemia.

In another study, being on a

differences

differences
cholesterol-lowering medication
Notes

also allowed patients to meet

by sex

by sex
criteria. A third study relied on
physician diagnosis of dyslipidemia
only. The sample sizes for 2 of these
.477
.826
.945
.458

.014
<.001

<.001
<.05

.16
<0.05

NR
NS
NS

NS

NS
.8
P

studies were more than 10 000

participants. In general, the
Healthy Overweight Class I Class II Class III

4.14

prevalence of dyslipidemia
increased when comparing healthy
weight with overweight and
4.20
156

156

overweight with obesity. When

comparing healthy weight with
4.20

3.76

3.78

3.94

3.94
161.3

162.1

HW, healthy weight; NR, not reported; NS, not significant; OB, obese; OW, overweight; PCOS, polycystic ovary syndrome; SO, severe obesity. obesity, the prevalence (or odds
168

156

ratio) nearly doubled. Caution

4.14
4.32

4.29
4.36
3.89
4.06

3.55

4.03

should be used when interpreting

3.9

3.9
170.0

these results given the inconsistent

definition of dyslipidemia.
4.04
4.29

4.18
4.33
3.94
4.15

3.66

3.83
129.8

132.1

156.5
3.7

3.9

Glucose Metabolism
4.05
4.30

4.20
Total

Hemoglobin A1c
A total of 7 studies examined the
11–18 y females
4–10 y females
11–18 y males

prevalence of abnormal hemoglobin

mmol/L 4–10 y males
Subgroup

A1c (HbA1c),13,26,28,34,37,38,41
Females

Females

Females

Females

Females
mmol/L Males

mg/dL Males

mg/dL Males

mmol/L Males

mmol/L Males

whereas 12 provided mean values

for HbA1c.6,13,40,41,46,55,63,67,73,79,81,
mmol/L

82
The participants in the 6 studies
Units

mg/dL

reporting abnormal HbA1c ranged

in age from 3 to 19 years, with
452

284

847

120
1944

1027

1332

3978

1 study only reporting the mean age

N

of 17 years (Table 10).26 This same

study also deviated from the
Median 12
Ages (y)

12–13
8–17

6–16

4–18

2–18

5–17

5–19

standard definitions of weight

classification and defined an
abnormal HBA1c level as greater
than 6.5%, whereas the other 5
Country

studies ranged from greater than

Denmark

5.6% to 6%. One study did not

Canada

Canada
France

Turkey

Korea
Israel

report the sample size whereas

UK
TABLE 8 Continued

others ranged in size from 101 to

Hadjiyannakis

8579. The prevalence of abnormal

Avnieli Velfer

Kloppenberg
First Author

glucose in overall cohorts ranged

Higgins
Botton

Serap

Craig

from 1% to 17%, with the latter

Kim

reported in a cohort of children 3 to

20 SKINNER et al
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 19 years of age. Using data from the

patients 1 some community

Pediatric weight management
Weight management program
National Health and Nutrition
Patients with type 1 diabetes

Weight management clinic

Weight management clinic

Weight management clinic

Bariatric surgery patients

Examination Survey (NHANES) 1999

Population Info

to 2012, 1 study cited a statistically

program patients
NHANES 1999–2014 significant difference between
glucose levels among the overweight
patients

patients

patients
mellitus

and obese groups (class I, II, and/or

III obesity).38
Weight Definitions

Most studies of mean HbA1c values

2: BMI 50–60,
3: BMI >60
1: BMI 30–50,

did not report significant differences

by weight, although none examined
differences by obesity severity
(Table 11). The only study with a
large sample size (n 5 11 348)
Notes
N 5 238

included children with type

1 diabetes mellitus seen in an
endocrine clinic; there were no
<.05

.02
NR

NR

NR

NR
NS
P

differences in mean HbA1c by

weight status.82 An additional study
Class II Class III
41.7

30.8

36.1

35.2

37

21

showed statistically significant, but

very small, differences by weight
53.2

68.7

40.2
17.0

36.3

38.4

category.55
24

23
OR 5 2.2
Class I

Glucose
52.2

53.7

32.5
27.6

37.2

34.8

28

17

A total of 37 studies examined the

Overweight

OR 5 1.4

prevalence of abnormal
38.0

26.3

glucose,5,6,8–14,17–23,25,26,28–32,
37–42,71,77,78,80,84–86
whereas 39
3.8% OR 5 1.0
Healthy

provided mean values for

22.7

20.0

glucose.5,6,8,10,13,18,22,32,35,36,40,41,43,44,
NHLBI, National Heart, Lung, and Blood Institute; NR, not reported; NS, not significant; OR, odds ratio.

46–49,52,54–56,58–62,65,66,68,70,71,73–75
Total
50.4

Thirty-seven studies reported

20

prevalence of abnormal glucose

TG > 130, or TC > 200

across weight groups in cohorts

HDL < 40, LDL > 130,

Any lipid abnormality

Physician diagnosed

NHLBI statement
Definition of

Any abnormal lipid

TG, low HDL, or

ranging from 3 to 19 years of age

Abnormal

Guided by 2011
medication

(Table 12). Twelve of these studies

High LDL or

reported significant differences, with

9 of these studies including a
healthy group comparator. Of those
Subgroup
(eg, M/F)

Females

studies indicating significant

23438 Males
TABLE 9 Prevalence of Dyslipidemia (n 5 6)

differences, prevalence sharply

increased across increasing weight
2–17.9 11348
242

154

431

847
N

category, including a multifold

higher prevalence in youth with
Ages (y)
13–19

12–19

14–24

5–17
2–5

obesity versus those with healthy

weight. Eight studies reported data
Germany
Country

Hadjiyannakis Canada

from nationally representative

USA

USA

Jayawardene USA

datasets, including in the United

US

States and Korea, with 5 of these

First Author
Michalsky

studies reporting significant

Redonco

Tsao-Wu

Lennerz

differences in prevalence across

weight categories.

PEDIATRICS Volume 151, number 2, February 2023 21

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 Prevalence of abnormal glucose in

Pediatric endocrinology

weight management
overall cohorts ranged from 0% to

program patients

program patients
Population Info
NHANES 2001–2002

NHANES 1999–2012
26.1%, with the latter reported in a
Stage 3 pediatric

Bariatric surgery

Indigenous youth
Pediatric weight
management
patients
cohort of adolescents undergoing

patients
bariatric surgery.26 This study also
reported the highest prevalence of
abnormal glucose among the studies
reviewed, with 37.5% of adolescents
with class III obesity indicated with
Definitions

1: BMI 30–50,
Weight

abnormal glucose. Seven studies

2: 50–60,
3: >60

reported prevalence separately by

biological sex, although there were
no consistent differences, with
Notes

males having higher prevalence in

4 studies and females having higher
prevalence in 2 studies. Importantly,
.873

<.001
.539
<.05

NR
NS

NS
P

studies varied in definition of

abnormal glucose, with 18 studies
Class III

using the threshold of $100 mg/dL,

13.19
42.3

4.2
18

16

7 studies using the threshold of

$110 mg/dL, and 2 studies using
Class II

[Typo]

6.38

the threshold of $126 mg/dL.

35.7

15

15

Thirty-nine studies reported mean

Class I

3.40
40.9
3.7

3.7

glucose levels across weight groups

13

13

in cohorts ranging from 3 to

Overweight

20 years of age, with 12 studies

1.87
0.3

detecting significant differences

25

12
9

(Table 13). Eight of these studies

included a healthy weight
Healthy

comparator, whereas 4
0.5

demonstrated significant differences

in glucose levels among the
Total
1.0

6.1
17

15

overweight and obese (class I, II,

and/or III obesity) groups.
Subgroup
(eg, M/F)

Significant differences in mean

glucose level across weight groups
were observed in multiple age
Definition of

ranges, including studies that

Abnormal
>5.7%

>5.7%

>6.5%

>5.7%
<6.0%
>5.7%
>5.6

consisted of both children and

adolescents, as well as a study of
TABLE 10 Prevalence of Abnormal HbA1c (n 5 7)

exclusively preschool-aged
101

382

242

158
847
8579

children.46 However, none of the

NR
N

subgroups had a mean glucose value

Mean 17
Ages (y)

above the standard threshold of

6–17
3–18

3–19

3–19
5–17
5–17

$100 mg/dL ($5.5 mmol/L) to

NR, not reported; NS, not significant.

indicate elevated fasting glucose.

Australia
Country

Canada

Insulin
US
US

US

US

US

A total of 14 studies examined the

Hadjiyannakis

prevalence of abnormal insulin,6,9,12,

First Author

Michalsky

19,22–24,26,28,34,39,41,42,84
Salvatore

whereas 32
Skinner

Skinner
O’Hara

Valery

provided mean values for

insulin.6,8,22,24,32,35,36,40–44,46,

22 SKINNER et al
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 47,49,52,54,55,58–62,65,66,70,71,73,75,84,87,88

Weight management 1
clinic 1 population-

clinic 1 population-
Children of minoritized
minoritized groups
Table 14 indicates that 8 of

Steatohepatitis clinic
program patients
Weight management

Weight management
Youth of minoritized

diabetes mellitus
Patients with type 2

some community
Population Info

12 studies observed significant

Indigenous youth
Pediatric weight
management
Youth of urban differences in prevalence of

patients
groups

groups
abnormal insulin across weight

based

based
categories, with a range of 0% in a
sample of 3- to 18-year-old
participants who were overweight
Weight Definitions

OW: 90th–99th,

OW: 90th–99th,
in the United States34 to 80% among

OB: >99th

OB: >99th
Assume CDC

HW: <90th,

HW: <90th,
9- to 16-year-old participants with
obesity in Canada.19 Prevalence
estimates were reported from
samples enrolled in the United

differences by

differences by
<.001 P value includes

<.001 P value includes

States (8 studies), 2 studies each in
Notes

Australia and Canada, and 1 study

each in Italy and Japan; however,

sex

sex
none of the studies were indicated
as nationally representative.
.053

.037
<.05

.75

.43
.03

.01

.14
NR
NS

NS

NS

Eight studies had less than

P

500 participants, but the sample

(eg, M/F) Total Healthy Overweight Class I Class II Class III

5.48 sizes ranged from 62 to 6358. Three

5.4

5.3
studies enrolled participants from
clinic-based settings, including a
5.37
5.3

5.2

pediatric gastroenterology clinic,

a pediatric weight management
5.16

4.65

5.24
34.24

34.18

program, and a bariatric surgery

4.9
5.4

8.2

8.4
8.8
5.4

5.3

5.2

program. Several definitions of

abnormal insulin were used, making
33.92
4.97

5.35

4.66

5.55
4.9

5.5

8.1

8.4
8.8
5.3

5.1

it difficult to compare actual

34

prevalence estimates across studies.

In several studies, youth with
4.96

5.43

4.60

5.39

33.7
4.9

5.4

8.2

8.3
8.8

obesity had a four- to fivefold higher

34

prevalence of abnormal insulin

5.3

5.3

compared with youth with healthy

weight. There were also differences
Subgroup

HW, healthy weight; NR, not reported; NS, not significant ; OB, obese; OW, overweight.
Females
13–17 y

observed within obesity

6–12 y

mmol/mol Males
2–5 y

classification: for example, youth

with class II or higher obesity had a
%, median

threefold higher prevalence of

Units
%
%

%
%

abnormal insulin than their peers

with class I obesity.22 One study
11 348

that did not observe significant

1185

Median 12 3978
N
283
148

198

199

158
847

431

767
75

differences in abnormal insulin

prevalence across weight categories
Mean 13
Ages (y)

14–24
14–18

10–18

11–14
6–13
6–13

2–17

5–17
5–17
3–5

comprised patients who were all

TABLE 11 Mean HbA1c (n 5 12)

enrolled in a bariatric surgery

program, so patients had
Netherlands
Country

Denmark
Australia
Australia

Australia

Germany

comorbidities at the time of entry.26

Hadjiyannakis Canada

The 1 study that examined

USA

USA

USA

USA

USA

abnormal insulin prevalence by age

Kloppenberg

did not observe differences between

First Author

Turchiano

McCarthy

Redondo

6- to 11-year-old versus 12- to 19-

Lennerz
Valery
Bocca
Watts

year-old youth.24 Three studies

Seth
Puri
Bell

reported prevalence stratified by

PEDIATRICS Volume 151, number 2, February 2023 23

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by guest
24
TABLE 12 Prevalence of Abnormal Glucose (n 5 31)
Definition of Subgroup Weight
First Author Country Ages (y) N Abnormal (eg, M/F) Total Healthy Overweight Class I Class II Class III P Notes Definitions Population Info

Kim Korea 10–19 931 >110 mg/dL 0.2 0.2 1.2 NA NA

Halley Castillo Mexico 7–24 1366 110-126 mg/dL 0.32 0.47 0.664 Patients in Central Mexico
Duncan USA 12–19 991 $110 mg/dL 1.1 0.6 4.0 0.1 NR NHANES 1999–2000
Davis USA 7–18 211 >100 mg/dL 12 15 18 NR Patients in rural Georgia
Bell Australia 6–13 283 >7.0 mmol/L 0 1.3 5.3 .037
Valerio Italy 3–16 150 110–126 mg/dL 0 0 0 OB >95th
Turchiano USA 14–18 1185 >100 mg/dL 0.6 0.3 2.0 .03 Youth of urban minoritized
groups
Skinner USA 6–17 NR 0.4 0.0 0.0 2.9 <.05 NHANES 2001–2002
Perez USA (Puerto 12–18 101 >100 mg/dL 1.9 1.9 1.0
Rico)
O’Hara USA 3–19 382 $100 mg/dL 8 4 7 7 11 NR Stage 3 pediatric weight
management program
patients
Marcus USA Mean 11.2 1305 >100 mg/dL 20.4 19.8 .7791
Michalsky USA 13–19 242 $100 mg/dL 26.1 17.7 31.2 37.5 .01 1: 30 < 50 BMI, Bariatric surgery patients
2: 50 < 60;
3: >60
Yoshinaga Japan 6–12 471 >100 Males 0.9 2.0
Females 6.7 0
Williams USA 12–19 915 100-125 mg/dL 5.4 2.8 17.8 <.05 NHANES
Skinner USA 3–19 8579 $100 mg/dL 15.56 19.42 31.77 24.27 .003 NHANES 1999–2012
Li USA 12–19 20905 >100 mg/dL 13.64 11.93 14.66 16.94 26.80 <.05

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Jayawardene USA 12–19 23438 >126 Males 0.6 0.9 0.3 4.2 NHANES 1999–2014
USA Females 0.6 1.1 0.5 0.8
Park, S Korea 10–19 1554 >100 mg/dL 5.6 5.2 12.2 <.05 2007-2008 KNHANES
Laurson USA 12–18.9 3385 Joliffe standards Males 16.4 19.5 24.1 NR NHANES
USA Females 6.5 8.3 12.1 NR NHANES
Baranowski USA 13.6 1740 >110 mg/dL 6.2 4.4 6.7 8.9 NR
Guerrero-Romero Mexico 6–18 1534 100-126 FG 18.3 17.1 18.8 19.1
Park Korea 12–19 664 $100 mg/dL 3.4 0 5.8
Caserta Italy 11–13 646 >100 mg/dL Males 0.7 3.3 3.8 NR
Females 0.0 0.0 3.5 NR
Marcus USA Mean 11.8 6358 >100 mg/dL No 13.5 15.5 20.2 22.5 .0003
Kim Korea 10–18 1412 >110 1998 KNHANES 8.2 9.4 5.3 NR
1158 2001 KNHANES 7.7 5.8 9.3 NR
Botton France 8–17 452 >6.1 mmol/L 1.0 0.0 NR
Del-Rio-Navarro Mexico 6–13 1819 >100 mg/dL 1.3 4.4 3.5
Pan US 12–19 4450 >100 mg/dL 13.3% 9.5 14.2 17.2 <.05 OB NHANES 1999–2002
Messiah USA 8–14 1698 >100 mg/dL 12–14: 12–14: 12–14:
12.30 9.61 21.83
Lambert Canada 9–16 3613 >5.6 mmol/L Males 16.4 24.4 24.7 .02
Females 9.1 9.1 17.3 .075
Valery Australia 5–17 158 NR 4 3 .829 Indigenous youth

SKINNER et al
 biological sex; in 2 of the studies,
females had higher prevalence of

Weight management clinic

Adolescent clinic patients
Adolescent clinic patients

management program

Community recruitment
abnormal insulin compared with
Population Info
Obesity clinic patients

Obesity clinic patients

patients 1 some
males.

Pediatric weight
Clinic patients

community
patients
Thirty of the 32 studies (Table 15)
reporting mean values of insulin
observed significant differences
across weight categories; the other 2
SO 120%/95th

SO 120%/95th

studies did not statistically test for

Definitions
Weight

differences among weight categories.

OB 95th,

OB 95th,

Although most (22 of 32) studies

examined differences between 2
weight categories (healthy versus
Notes

combined overweight and obese), 10

of the 32 studies reported mean
.867
.493

.005
NR

NR

NR

NR

insulin values for at least 3 weight

P

categories; in every case, there was

Healthy Overweight Class I Class II Class III

a noticeable dose-gradient
4

20

relationship of insulin across the

multiple weight categories and the P
value was significant. These
3

19

differences were noted among

14.5
13.9

healthy versus overweight versus

KNHANES, Korean National Health and Nutrition Examination Survey; NR, not reported; NS, not significant ; OB, obese; SO, severe obesity.
4

obesity groups as well as a study of

adolescents that observed
21.2
11.2

differences among healthy,

1

overweight, obesity class I, and

obesity class II1.24 Most of the
3

cohorts spanned the age range from

childhood to adolescence, although 1
Total

study observed significant

3

differences in insulin values among

Subgroup
(eg, M/F)

3- to 5-year-old children who were

Females

Females

overweight versus those who had

Males

Males

obesity,46 and a second study also

observed significant differences
Definition of

among 6- to 8-year-old children

Abnormal

847 >6.1 mmol/L

1027 >100 mg/dL

300 >100 mg/dL

363 >100 mg/dL

431 >110 mg/dL

62 >100 mg/dL

with healthy weight versus those

with obesity.52 Two studies reported
mean values by age24,71; in both
cases, the insulin levels were higher
N

in adolescents versus children, and

Ages (y)

the insulin values were noticeably

2–18

8–17

5–17
11–18

14–24

12–17

higher among the youth with higher

weight status.
Country

Germany

HOMA-IR
Canada
Israel

USA
USA

USA
TABLE 12 Continued

A total of 10 studies examined the

prevalence of abnormal homeostatic
Hadjiyannakis

model assessment for insulin

Avnieli Velfer

Fyfe-Johnson
First Author

resistance (HOMA-IR),7,9,12,26,32,35,
Stolzman
Lennerz
Gunes

40,71,88,89
whereas 25 provided mean
values for HOMA-IR.7,32,35,36,40,41,43,

PEDIATRICS Volume 151, number 2, February 2023 25

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by guest
26
TABLE 13 Mean Glucose (n 5 39)
Subgroup Weight
First Author Country Ages (y) N Units (eg, M/F) Total Healthy Overweight Class I Class II Class III P Notes Definitions Population Info
Kollias Greece 6–13 780 mg/dL 90.8 92.2 90.7 NS
Davis USA 7–18 211 mg/dL 90 90 92 NS Patients in rural
Georgia
Bonet Spain Mean 10.7 101 mM 4.0 4.2 NS Patients were all
white
Bell Australia 6–13 283 mmol/L 4.67 4.67 4.75 .783
Baer USA 12–22 173 mg/dL 83.8 83.7 82.0 84.4 .61 Females with PCOS
Aylanc Turkey Mean 5 13.5 88 mg/dL 87.9 93.8 .004
Akinci Turkey 6–17 41 mmol/L 5.17 4.94 .665 Control: 25th–74th
percentile
Zabarsky USA 7–20 2244 mg/dL 91 92 93 93 .006 IV 5 93 Includes class IV
Valerio Italy 3–16 150 mg/dL Children 80.6 81 NS OB >95th
Adolescents 73.8 82.8 <.001
Valentini Italy 5–18 84 mg/dL 83.38 88.32 .017 Patients with Down
syndrome
Watts Australia 6–13 148 mmol/L 4.5 4.5 4.5 NS
Turchiano USA 14–18 1185 mg/dL 79.2 79.4 81.4 <.05 Youth of urban
minoritized
groups
Simsek Turkey Mean 11 115 mmol/L 4.7 4.8 .737
Salawi Canada 6–19 345 mmol/L 4.9 4.9 .7
Rank Germany 6–19 463 mg/dL Males 70.2 71.5 .480
Females 71.9 75.5 .051

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Perichart-Perera Mexico 9–12 88 mg/dL 75.30 77.13 75.91 NS
Perez USA (Puerto 12–18 101 mg/dL 85.4 86.4 .40
Rico)
Nystrom Spain 8–11 1247 mg/dL 83.4 84.3 85.6 85.9 SO >99.8th
Nascimento Portugal 5–18 181 mmol/L 4.90 5.00 .174
Olza Spain 6–12 446 mg/dL Males 84 85 .340
Females 83 84 .629
Marcus USA Mean 11.2 1305 mg/dL 94.6 94.2 .3075
Weiss USA 12–17 1418 mg/dL 90 90 93 94 <.001
Buchan UK 5–12 223 mmol/L 4.83 4.93 .182
Bocca The Netherlands 3–5 75 mmol/L 4.2 4.0 4.3 <.05
Baranowski USA Mean 13.6 1740 mg/dL 98.2 97.3 98.3 99.9 .0172
Garces Spain 6–8 1048 mg/dL Males 91.6 93.8 .08
Females 89.5 90.1 .74
Guerrero-Romero Mexico 6–18 1534 mg/dL 90.2 90.7 93.6
Cizmecioglu USA 10–19 310 mg/dL 886 89.6 89.6 NS
Norris USA Mean 13.5 225 mg/dL 85.1 88.7 92.5 .770
Kim Korea 10–18 1412 mg/dL 1998 males 94.7 94.3 95.9 .813
1998 females 92.4 94.9 93.4 .174
1158 2001 males 94.6 95.6 97.7 .183
2001 females 93.6 92.0 93.7 .668

SKINNER et al
 45,46,49,52,54,58,59,61–63,65,66,70,71,73,75,

program patients

Weight management
clinic patients 1
population-based
81,90
Population Info

Prevalence of abnormal HOMA-

Indigenous youth
endocrinology

Pediatric weight
management
IR ranged from 0% in healthy

School based
Obesity clinic
patients

patients
adolescents71 to 70.8% in
Pediatric

Schools
adolescents with class III obesity
who were enrolled in a bariatric
surgery program26 (Table 16).

OB 95th, SO 120%/

OW: 90th–99th,
However, definitions of abnormal
Definitions
Weight

OB: >99th
HOMA-IR differed in every study, so

HW: <90th,
95th it is difficult to compare prevalence
estimates. Prevalence was reported
for cohorts from the United States

P value includes
(5 studies) and Europe (5 studies);

differences
however, none were indicated as
Notes

by sex
nationally representative cohorts.
Prevalence of abnormal HOMA-IR
was significantly different across
.318

.707
<.005

.014
.215
0.005
weight categories in 7 of the
<.05
<.05

.93

.04
NS
NS
NS

NS
P

NR

9 studies; 1 study did not

Total Healthy Overweight Class I Class II Class III

statistically examine differences

4.90

across weight categories and

another study did not observe
4.90

differences, but the sample only

90

91

HW, healthy weight; NR, not reported; NS, not significant; OB, obese; OW, overweight; PCOS, polycystic ovary syndrome; SO, severe obesity.

consisted of adolescents with

4.80

5.2

5.1
92.4

92.2
83.0
79.8

obesity who were undergoing

90

84

bariatric surgery (with no

differences among class I, class II, or
4.82
4.80

4.89
82.1
78.7

90.0

90.7
88.8
5.1

5.0

class III obesity; Michalsky/US).26

One study reported prevalence by
4.75
4.63

4.66

age group with a stark difference in

5.0

5.0
92.1

92.6
79.5
77.2

90.0

89.0
87.9

abnormal HOMA-IR in both children

4.76
4.65

4.90

and adolescents with obesity

89.3
88.0

(approximately 41%) versus

participants with healthy weight
Subgroup
(eg, M/F)

(0% to 3%) (Valerio/Italy).71 Two

Females

Females

Females

Females

Females

Females
452 mmol/L Males

284 mg/dL Males

Males

1027 mg/dL Males

3978 mmol/L Males

Males

studies reported prevalence

stratified by biological sex; in both
158 mmol/L

847 mmol/L
Units

1819 mg/dL

120 mg/dL

1679 mg/dL

cases, prevalence of abnormal

HOMA-IR was higher among females
compared with males (Caserta/Italy;
N

Serap/Turkey).9,35
Median 12
Ages (y)

12–13

12–18
8–17

6–16

6–13

5–17
2–18

5–17

Studies reporting mean HOMA-IR

across weight categories (Table 17)
corroborated the findings of the
prevalence of abnormal HOMA-IR.
Country

Denmark

Twenty-three of the 25 studies

Australia

Canada
Mexico
France

Turkey

Japan
Korea
Israel

reported significant differences in

TABLE 13 Continued

HOMA-IR value across weight

Del- Rio-Navarro

categories. Most of these studies

Hadjiyannakis
Avnieli Velfer

Kloppenberg

examined differences between

First Author

Sougawa

healthy weight versus overweight

Botton

Valery
Serap

and obesity combined. However,

Kim

6 studies examined differences

PEDIATRICS Volume 151, number 2, February 2023 27

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 across 3 weight categories, showing

Adolescent clinic patients

Adolescent clinic patients
management program
Stage 3 pediatric weight

Community recruitment
a gradient of HOMA-IR values
Population Info

gastroenterology
among healthy weight, overweight,

Bariatric surgery

Indigenous youth
and obesity. One study reported
patients

patients

patients
mean values separately by age
Pediatric

group, with adolescents having

higher HOMA-IR values than
children in both the healthy weight
BMI, 2: 50 < 60;
and obesity categories.71 Four
Definitions

studies reported mean HOMA-IR

Weight

1: 30 < 50

3: >60
values stratified by sex; there was
not a consistent pattern in differing
values between females and males.
Notes

Most cohorts included both children

and adolescents or only adolescents;
<.0001

<.0001

<.0001
<.001
.301

<.001

.021
.347
<.001
NR
NR
NR
NS

>.99

<.05
<.05

<.05

<.05

<.05
however, the 1 cohort that did
P

include young children (ages 3–5

Class III

years) did not observe a significant

72.2

75.0

40.0
57

differences in HOMA-IR across

weight categories.46 A cohort of
Class II

56.5

35.7
74.0

children ages 6 to 8 years did

40

observe significantly higher

HOMA-IR values among children
Class I
38.9
47.4

10.5
73.9

60.8

72.3
60.4

65.5
13.4
72.1

80.1

12.8
24.5
34

33

with obesity versus children with

healthy weight.52
Overweight

3.0

6.6
1.7
19.5

50.2
49.3
36.2
25.6

38.2

37.2

46.3

Other Glucose Metabolism

0

29

45

56

Additional studies reported the

Healthy

prevalence of prediabetes
47.7

18.0
11.6
16.0
12.4

11.2

11.3

23.2
8.0

0.8

30

(n 5 3),13,85,91 diabetes mellitus

(n 5 8),13,26,33,71,83,85,87,92 and
Total

74.1

20.5

36.2

metabolic syndrome (n 5 16).10,11,14,

42

17,20,29–32,35,42,49,93–96
Three studies
Subgroup
(eg, M/F)

Females

Females

Females

Females
12–19 y

reported prevalence of prediabetes

6–11 y
Males

Males

Males

Males

(Table 18). The population-based

study in Mexico defined prediabetes
>13.2 females

>60 13–16 y

as 2-hour glucose tolerance test

Definition of

>17.0 ulU/mL
Abnormal

>20 mIU/mL

<15.0 mU/L

result of 140 to 200 mg/dL.

>11 males,
>30 uU/mL

>30 uU/mL

>30 uU/mL

>15 uU/mL
>12 mIU/L

>38 9 y,

Prediabetes was higher in children

TABLE 14 Prevalence of Abnormal Insulin (n 5 14)

>90th

>75th
>10

>30

with overweight or obesity versus

children with healthy weight.85 A
62
283
101

382

242

471

646

158
363
1305

2087

1740

6358
3613

second population-based Canadian

N

study showed greater risk of

Mean 11.2

Mean 13.6

Mean 11.8
Ages (y)

prediabetes for children with obesity

6–13
3–18

3–19

6–12

6–11

9–16

5–17
13–19

11–13

11–18

12–17

versus children with healthy

NR, not reported; NS, not significant.

weight.91
Australia

Australia
Country

Canada

Canada
Japan

The 8 studies reporting the

Italy
USA

USA

USA
USA

USA

USA

USA

USA

prevalence of diabetes (Table 19)

First Author

used varying definitions of diabetes,

Baranowski
Yoshinaga

Maximova
Michalsky
Salvatore

Stolzman
Lambert

based on fasting plasma glucose,

Caserta
Marcus

Marcus
O’Hara

Valery
Gunes

glucose tolerance tests, HbA1c,

Bell

diagnosis, or use of medications.

28 SKINNER et al
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TABLE 15 Mean Insulin (n 5 32)
Subgroup
First Author Country Ages (Y) N Units (eg, M/F) Total Healthy Overweight Class I Class II Class III P Notes Weight definitions Population Info
Bonet Spain Mean 5 10.7 101 mU/l 6.1 14.3 <.001
Bell Australia 6–13 283 mU/L 5.96 8.21 14.67 <.001
Baer USA 12–22 173 uU/mL 21.7 9.6 14.3 26.7 <.001 Females with PCOS
Aylanc Turkey Mean 5 13.5 88 uU/mL 10.38 25.61 <.001
Akinci Turkey 6–17 41 uU/mL 4.28 7.50 .005 HW:25th–75th
Valerio Italy 3–16 150 uU/mL Children 6.8 12.4 .0001 OB > 95th
Adolescents 7.6 20.8 .0001
Valentini Italy 5–18 84 mU/L 10.28 16.9 .001 Patients with Down
syndrome
Watts Australia 6–13 148 mU/L 5.9 7.7 9.8 <.05 Assume CDC
Turchiano USA 14–18 1185 uU/mL 10.0 12.0 18.6 <.05 Youth of urban
minoritized groups
Simsek Turkey Mean 5 11 115 uU/mL 6.6 14.5 <.001
Salawi Canada 6–19 345 l/L 18.5 31.3 .02 Patients referred to
pediatric weight
management

PEDIATRICS Volume 151, number 2, February 2023

program
Rank Germany 6–19 463 l/l Males 8.7 12.0 <.001
Females 10.1 14.6 <.001
Perichart-Perera Mexico 9–12 88 uU/mL 29.73 38.16 53.11 .001
Perez USA (Puerto Rico) 12–18 101 uU/mL 8.3 18.5 <.001
Nystrom Spain 8–11 1247 uU/L 6.6 9.0 12.9 15.9 SO >99.8th
Nascimento Portugal 5–18 181 mmol/l 5.28 12.95 <.001
Olza Spain 6–12 446 l/l Males 4.99 10.38 <.001
Females 5.41 12.21 <.001
Marcus USA Mean 5 11.2 1305 uU/mL 17.9 28.7 <.0001
Yoshinaga Japan 6–12 471 uU/mL Males 10.0 12.1 <.05
Females 13.2 14.3 NR
Weiss USA 12–17 1418 uU/mL 18 25 34 40 <.001

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Maximova Canada 6–19 2087 pmol/L Age 6–11 45.4 75.3 NR
Age 12–19 53.5 109 NR
Bocca The Netherlands 3–5 75 mU/L 7.9 6.2 8.9 <.01
Baranowski USA Mean 5 13.6 1740 uU/mL 30.1 22.5 28.9 44.8 <.0001
Garces Spain 6–8 1048 uU/mL Males 3.02 5.32 <.001
Females 3.46 5.33 <.001
Cizmecioglu USA 10–19 310 l/L 8.55 10.2 12.2 <.001
Norris USA Mean 5 13.5 225 mU/L 8.1 12.0 20.9 <.0001
Botton France 8–17 452 pmol/L Males 33.1 31.3 54.8 <.0001
Females 39.3 37.7 52.3 <.05
Serap Turkey 6–16 284 uU/mL Males 7.2 15.1 <.001 Pediatric endocrinology
patients
Females 6.7 17.7 <.001
Manios Greece 10–12 522 uU/mL 4.5 8.5 <.001
Valery Australia 5–17 158 l/L 11.96 18.74 .001 Indigenous youth
Kim Korea 12–13 120 uU/mL 8.8 14.4 <.001 School based
Kloppenberg Denmark Median 12 3978 pmol/L Males 51.2 69.4 105.4 <.001 P value includes HW: <90th, Weight management
differences OW: 90th–99th, clinic patients 1
by sex OB: >99th population-based
Females 62.2 85.4 122.8 <.001 P value includes HW: <90th, Weight management
differences OW: 90th–99th, clinic patients 1
by sex OB: >99th population-based
HW, healthy weight; NR, not reported; OB, obese; OW, overweight; PCOS, polycystic ovary syndrome; SO, severe obesity.

29
 Most studies showed significantly

Pediatric endocrinology
minoritized groups
higher prevalence of diabetes among
Population Info

children with obesity or severe

Bariatric surgery

Adolescent clinic

Adolescent clinic
Youth of urban
obesity, although overall prevalence

patients

patients

patients

patients
was low. Prevalence of diabetes
>3% was seen only in a pediatric
endocrinology clinic33 and among
bariatric surgery candidates.26
1: 30 < 50 BMI,
2: 50 < 60;
definitions
Weight

3: >60
Of the 16 studies assessing the
prevalence of metabolic syndrome
(Table 20), the largest sample
size was 4450 and the smallest
Notes

sample was 101. Seven studies

reported the prevalence of
<.001
<.001

<.002
<.001

<.001

<.001

<.001
<.001

.402

<.001
>.99

<.05

<.05
P

metabolic syndrome as the presence

of 3 or more components of
Class III

70.8

metabolic syndrome in cohorts

ranging from 6 to 24 years of age,
with 3 of the studies conducted in
Class II

71.2

the United States. The remainder of

the studies (8) reported the presence
Class I
62.5
40.8

41.2
37.8

66.7
71.2

54.7

65.5
47.2

56.7
31.0

44.7

of metabolic syndrome using the

68

following criteria: Adult Treatment

Panel (ATP) III (2 studies), NCEP ATP
Overweight

12.4

81.3

36.5

26.7

37.1

10.5

48.2

III (2 studies), 3 components plus

60

risks (2 studies), 3 components plus

abnormalities (1 study), and
Healthy
22.7

35.6

10.9

13.1

11.8
4.5

3.8

8.6
2.9

International Diabetes Foundation

3

(IDF) (1 study). Of the 16 studies,

14 included a healthy weight
Total

17.8
71.1

9.2

comparison, and 11 of the studies

reported a significant association
Adolescents
Subgroup
(eg, M/F)

Children

Females

Females

Females

between the prevalence of metabolic

Males

Males

Males

syndrome and overweight. Of the

No

No

studies that defined the presence of

>4.0 adolescents

metabolic syndrome as having 3 or

>2.67 females
of Abnormal

more components and compared

Definition

%ile of NW)
>2.5 children;

>2.10 (97.5th
>2.28 males,

prevalence across children with

normal weight, overweight, and
TABLE 16 Prevalence of Abnormal HOMA-IR (n 5 10)

>95th
$3.16
>3.99

$4.0
>2.7

>2.5

3.16

obesity, the prevalence of metabolic

syndrome ranged from 0% to 4.7%
151
150

101

242

646

284

522

363
1185

3348

among children with healthy weight

N

and increased to 14.5% to 35%

3–10.9
Ages (y)

3–16

6–16
11–14

14–18

12–18

13–19

11–13

10–12

11–18

among children and adolescents with

class I obesity. Of the 2 studies that
defined metabolic syndrome as ATP
US (Puerto
Country

III and compared prevalence across

Rico)
Europe

Greece
Turkey

children with healthy weight,

Italy

Italy
USA

USA

USA

USA

overweight, and obesity, the

NW, normal weight.
First Author

prevalence of metabolic syndrome

Michalsky
Turchiano

ranged from 0.3% to 1.6%, which

Caserta
Bindler

Manios
Peplies
Valerio

Gunes
Serap
Perez

increased to 39% for children with

class I obesity in 1 study. One of

30 SKINNER et al
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TABLE 17 Mean HOMA-IR (n 5 25)
Subgroup Weight
First Author Country Ages (y) N (eg, M/F) Total Healthy Overweight Class I Class II Class III P Notes definitions Population Info
Aylanc Turkey Mean 5 13.5 88 1.43 5.80 <.001
Bindler USA 11–14 151 2.32 4.61 <.001
Akinci Turkey 6–17 41 1.01 1.67 .031 HW: 25th–75th
Valerio Italy 3–16 150 Children 1.4 2.5 .0001
Adolescents 1.4 4.2 .0001
Valentini Italy 5–18 84 2.18 3.69 .002 Patients with Down
syndrome
Watts Australia 6–13 148 1.1 1.6 2.0 <.05
Turchiano USA 14–18 1185 2.0 2.3 3.8 <.05 Youth of urban
minoritized groups
Simsek Turkey Mean 5 10.8 115 1.38 3.11 <.001
Salawi Canada 6–19 345 4.0 6.8 .03 Patients referred to

PEDIATRICS Volume 151, number 2, February 2023

pediatric weight
management
program
Puri USA 10–18 198 2.1 6.4 <.001 Youth of minoritized
groups
Rank Germany 6–19 463 Males 1.5 2.2 <.001
Females 1.8 2.7 <.001
Perichart-Perera Mexico 9–12 88 5.90 7.23 9.97 .001
Perez US (Puerto Rico) 12–18 101 1.8 4.1 <.001
Nascimento Portugal 5–18 181 1.14 2.90 <.001
Olza Spain 6–12 446 Males 1.04 2.21 <.001

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Females 1.14 2.58 <.001
Buchan UK 12–17 387 1.4 1.1 .064
Bocca The Netherlands 3–5 75 0.79 1.14 <.01
Bindler US Mean 5 12.5 150 2.32 4.66 <.001
Garces Spain 6–8 1048 Males 0.69 1.26 <.001
Females 0.76 1.18 <.001
Cizmecioglu USA 10–19 310 No 2.3 2.4 2.7 .006
Norris USA Mean 5 13.5 225 No 1.7 2.6 4.4 <.0001
Serap Turkey 6–16 284 Males 1.7 3.5 <.001 Pediatric endocrinology
patients
Females 1.6 3.8 <.001
Valery Australia 5–17 158 No 2.25 3.58 .002 Median Indigenous youth
Lennerz Germany 14–24 431 4.23 5.57 7.37 <.001 Weight management
program patients 1
some community
Kim Korea 12–13 120 2.0 3.2 <.001 School based
HW, healthy weight.

31
 the 2 studies did not report SBP.5,7,8,10,13,18,22,24,32,33,35,36,39,40,

program patients
42–46,48–50,54–56,59–66,68,71–75,77,79,83,
prevalence for class I obesity. Of
Population Info

Population based
Pediatric weight
management
90,97,99,102–108
the 2 studies that defined metabolic Twenty-one studies,
syndrome as NCEP ATP III and including children ages 3 to
compared prevalence across 19 years, examined the prevalence
children with healthy weight, of elevated SBP in relation to excess
overweight, and obesity, the weight (Table 21). Within the
Notes Definitions

17 studies formally testing such an

Weight

prevalence of metabolic syndrome

WHO

ranged from ranged from 1% to association, 14 included a healthy

1.5%, which increased to 28.6% to weight comparison group, and all
41% for children with class 1 obesity. but 1 of these reported a significant
Of the 2 studies that defined association between the prevalence
<.05

metabolic syndrome using of elevated SBP and overweight or

NR
P

3 components plus risk and obesity.

Class II Class III

compared prevalence across children

6

with healthy weight, overweight, and Reported frequencies further

obesity, the reported prevalence of suggest a progressive increase in the
metabolic syndrome ranged from 0% prevalence of high SBP with
5

to 0.8% for females and 1.7% for increasing adiposity, although

limited information is available
aOR 5 1.53

males, which increased to 1.6% to

Class I

regarding differences across classes

5.7

24.6% for female children and 35%

3

for male children with class 1 obesity. of obesity, because only 1 study
One study defined metabolic specifically focused on such
Total Healthy Overweight

syndrome as 3 components plus categories. Studies supporting an

3.5

abnormalities and the reported association between elevated SBP

prevalence across children with and unhealthy weight status
healthy weight, overweight, and included samples based within
Ref

the United States (n 5 7) and

1.4

obesity was 0.2% among children

with healthy weight and 25.6% other countries (n 5 10) as well
as population-based and more
4

among children and adolescents

with class 1 obesity. When using targeted samples. Five studies
Canadian Diabetes Association

the IDF definition of metabolic reported statistical comparisons by

syndrome, the reported prevalence biological sex, all of which supported
>6.1 FPG or >7.8 OGTT
of Abnormal

a significant relationship between

140–200 2-h glucose

was 1.6% among children with

Definition

elevated SBP and unhealthy weight

aOR, adjusted odds ratio; FPG, fasting plasma glucose; OGTT, oral glucose tolerance test.

healthy weight and 28% among

children and adolescents with class 1 status for both males and females.
obesity. In addition, 3 studies Five studies based on samples
reported statistical comparisons by within a preteen or young-teenage
biological sex. However, only 1 range (eg, 9–13 years) supported
an association between higher SBP
Subgroup
(eg, M/F)

supported a significant relationship

between metabolic syndrome and and unhealthy weight. Prevalence
comparisons were not available
unhealthy weight status for both
TABLE 18 Prevalence of Prediabetes (n 5 3)

within studies for different age

1534
3449
847

males and females. Prevalence

N

subgroups, and no studies focused

comparisons were not available
specifically on young children
Country Ages (y)

within studies for different age

6–18
6–19
5–17

(eg, #8 years).
subgroups.
Fifty-two studies including children
Canada
Canada

Blood Pressure
Guerrero-Romero Mexico

ages 2 to 19 years provided mean

Systolic Blood Pressure values for SBP across different
A total of 21 studies examined the weight groups, including 21 studies
Hadjiyannakis

prevalence of abnormal systolic from the United States (with 2 from

First Author

blood pressure (SBP),5,7,8,10,13,15,18, Puerto Rico) and studies from

19,24,35–39,63,97–101
Rodd

whereas 15 other countries, spanning

52 provided mean values for 4 continents (Table 22). Within the

32 SKINNER et al
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 46 studies formally testing

Pediatric endocrinology
differences across means,

program patients
Weight management

Weight management

Weight management
Population Info

37 included a healthy weight

1: 30 < 50 BMI, Bariatric surgery

clinic patients

clinic patients

clinic patients
Military recruits

Pediatric weight
management
patients
comparison group, 32 of which
patients reported significant increases in
mean SBP with excess weight.
Among studies with a healthy
weight comparator, 8 specifically
2: 50 < 60;
Definitions
Weight

compared the healthy weight and

3: >60

overweight group or tested a trend,

with 6 supporting significant
increases in SBP with unhealthy
Notes

weight. Seven other studies

<.001

<.001
<.001
.015

compared only groups with

.55

NR

NR

NR

NR
P

overweight and obesity or different

Class III

classes of obesity, with 6 reporting

52.4

16.0

4.0

6.2
2

0
0%
0%

significant increases in SBP with

increasing adiposity. These findings
0.022452504
Class II

and reported means add support to

observed differences in prevalence
4.0

1.4
15.6

by weight status group—that is, that

0.028985507

SBP increases progressively with the

Class I

degree of overweight or obesity.

0.4%
0.1%

Studies reporting mean SBP also add

39.8

11.3

1.3

1.0

2.0
0

to previous insights by providing

Healthy Overweight

additional comparisons within sex

0.05%
0.03%
0.5

and age subgroups. Of the

0

18 studies including formal

ADA, American Diabetes Association; FPG, fasting plasma glucose; NR, not reported; OGTT, oral glucose tolerance test.
0.01% 0.001%

subgroup comparisons,
0.036% 0.02%

0.0

16 compared weight status

0

categories within both males and

Total

0.6
13.6

females. Most reported significant

0

differences across weight groups in

Subgroup
(eg, M/F)

Females

the expected direction for both

Males

males and females. Only 3 studies

reported comparisons for subgroups
1534 $200 mg/dL 2-h postload
2-h OGTT $200 mg/dL
FPG $126 mg/dL; or

by age, and 2 of these only

242 Diagnosis, medication,

847 >7.0 FPG, >11.0 OGTT

150 FPG > 126 mg/dL or
2-h >200 mg/dL
of Abnormal

compared younger and older

Definition

1418 ADA definitions

A1c $6.5%,

children and adolescents, although

154 HgA1c >6.5%

2 studies also compared means by

76732 Type 2

age for both males and females.

1111 >6.4

Also, 1 study compared means for

880

1004

4 age subgroups, ranging from 2 to

TABLE 19 Prevalence of Diabetes (n 5 8)

5 years to 16 to 19 years.102 In
Mean 12.7

addition to the general observation

Ages (y)

13–19

12–17

12–17
3–16

6–18
5–17

6–11
2–5
17

of increased SBP with age,

significant differences in SBP were
Country

Canada
Guerrero-Romero Mexico

reported by weight status for all

Israel
Italy

USA

USA

USA

USA

comparisons, regardless of age or

sex. Although few studies addressed
changes in SBP for very young
Hadjiyannakis
First Author

Bar Dayan
Michalsky

children, it should also be noted that

Tsao-Wu
Valerio

Propst

Weiss

2 other studies reported similar

findings for cohorts 6 years or

PEDIATRICS Volume 151, number 2, February 2023 33

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 younger.46,105 Combined prevalence

2007–2008 KNHANES
and mean tables for SBP support

NHANES 1999–2002
Population Info

endocrinology
Patients in rural
progressive increases in SBP and the
prevalence of elevated SBP with

patients
Georgia

Pediatric
NHANES

NHANES
increasing adiposity. The available

School
studies further suggest that this
finding holds in males and females

thresholds
Definitions

and is likely generalizable across

Weight

age, although limited evidence is

IOTF
still available relevant to younger
subgroups.
Notes

Diastolic Blood Pressure

<.0001 OB
A total of 19 studies examined the
<.0001

NR
NR
NR
<.000
<.001
<.001
<.001

<.001
<.001
<.001
<.001
P

prevalence of abnormal diastolic

<.05

blood pressure (DBP),5,7,8,10,13,15,18,

24,25,35–39,63,97,98,100,101
Class III

whereas 51
provided mean values for
DBP.5,7,8,10,13,18,22,24,32,33,35,36,39,40,
Class II

42–46,48–50,54–56,59–66,68,71–75,77,79,83,
90,97,99,102,103,105–108
Sixteen studies
reported on the prevalence of
Class I

28.6%

39.1%

1.6
35.0

32.1

16.2
20.6
23.7
35.4
24.6
28.1
25.6

14.5
31.6

abnormal DBP across weight groups

41

in cohorts ranging from 3 to

IOTF, International Obesity Task Force; KNHANES, Korean National Health and Nutrition Examination Survey; NR, not reported; OB, obese.
Overweight

19 years of age, with 7 of the

2.8%
12.0%
9.4

7.1

8.9
8.3
2.8
6.8
9.2
5.5
5.8

2.1
2.9
52.8

21.3
22.3
35.4

studies conducted in the United

15

States (Table 23). The majority of

Healthy

the studies (13 of 19) defined

1.5%

0.3%
1.7
4.7

1.6
1.6

0.0
0.8
1.7

0.2

0.9
0.1

abnormal DBP as a DBP >95th

0
1

percentile for age, height, and

Total

5.7%

4.1%
6.4

6.4

6.1
5.0

7.9
6.7
1.6

2.6

biological sex. Five studies defined

abnormal DBP as DBP >90th
Subgroup
(eg, M/F)

Females

Females

Females

percentile, and 1 study from Canada

Males

Males

Males

defined abnormal DBP as DBP

>75th percentile. Of the studies that
31 abnormalities

defined abnormal DBP as >95th

31 components
31 components

31 components

31 components
31 components

31 components

31 components
of abnormal
Definition

percentile and compared prevalence

NCEP ATP III

NCEP ATP III

IDF criteria
31 risks

31 risks

across children with healthy weight,

ATP III
ATP III

overweight, and obesity, the

IDF
TABLE 20 Prevalence of Metabolic Syndrome (n 5 16)

prevalence of abnormal DBP ranged

931

379
991
211

506

101
471

310
664
284
1366

1393

1554
3385

4450
1578

from 0% to 9.4% among children

N

with healthy weight and increased

Ages (y)

12–16.9

12–18.9
10–19

12–19

16–19
12–13

12–18

10–19

10–19
12–19

12–19
12–17

to 4% to 20% among children and

7–24

7–18

6–12

6–16

adolescents with class 1 obesity. Of

the studies that defined abnormal
US (Puerto Rico)

DBP as >90th percentile, prevalence

Country

of abnormal DBP for children with

Belgium
Mexico

Greece

normal weight ranged from 4% to

Turkey

Turkey
Japan
Korea

Korea

Korea

Korea
Spain
USA
USA

USA

USA

9.7%, which increased to 9% to

29.4% (among males) for children
Galera-Martinez
Halley Castillo

with class 1 obesity. Across all

First Author

Cizmecioglu

Bacopoulou
Yoshinaga

studies, age ranged from 3 to 19

Laurson
Duncan

Vissers

Serap
Perez

years, with only 2 studies examining

Davis

Park

Park
Kim

Pan
Ryu

abnormal DBP by age group.24,25

34 SKINNER et al
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TABLE 21 Prevalence of Abnormal Systolic Blood Pressure (n 5 21)
Definition Subgroup Weight
First Author Country Ages (y) N of Abnormal (eg, M/F) Total Healthy Overweight Class I Class II Class III P Notes Definitions Population Info
Ice USA 9–13 29286 >95th 7.9 13.4 23.4 <.01 Appalachian
population
Davis USA 7–18 211 (160 >90th 6 16 45 <.001 Rural Georgia
for lipids)
Bindler USA 11–14 151 >90th 2.9 17.1 .003
Turconi Italy 14–17 532 >95th Males 10.1 35.4
Females 4.8 22.7
Skinner USA 6–17 NR >95th 3.4 1.6 4.5 9.0 <.01 NHANES 2001–2002
Simsek Turkey Mean 10.8 115 >95th 0 13.3 <.001 OB >97th
Puri USA 10–18 198 >95th 3 28 .002 General pediatrics
and endocrinology
patients
Maggio Switzerland Mean 8.8 66 >95th 0 20.5 .029 OB >97th
Skinner USA 3–19 8579 >95th 3.22 5.02 8.52 11.10 <.001 NHANES 1999–2012
Maximova Canada 6–19 2087 >75th 6–11 y 18 33.2 NR
12–19 y 18 38.2 NR

PEDIATRICS Volume 151, number 2, February 2023

Krzyzaniak Poland 10–18 4904 $90th, 3 d Males 11.6 7.8 18.8 45.1 .000
Females 11.8 8.9 21.1 50.9 .000
Stray-Pederson Norway 15–18 2156 >95th 16.6% ref OR 5 3.8 OR 5 28.3
Kim Korea 10–18 1412 >95th 1998 KNHANES 9.1 20.0 28.9 <.05
1158 2001 KNHANES 5.2 9.6 22.7 <.05
Botton France 8–17 452 >95th 3.2 13 0.01 OW >90th
Harding UK 11–13 6407 >95th Males 2.7 OR 5 1.0 OR 5 2.50 OR 5 4.31 <.05
Females 3.8 OR 5 1.0 OR 5 3.39 OR 5 5.68 <.05
Serap Turkey 6–16 284 >95th Males 3.8 19.1 <.001 Pediatric
endocrinology
patients
Females 4.3 16.5 <.001
Messiah USA 8–14 1698 >90th 8–11 y 4.97 14.81 19.02

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12–14 y 2.26 11.36 20.87
Lambert Canada 9–16 3613 >90th Males 16.5 28.8 39.6 <.0001
>90th Females 11.8 27.4 40.6 <.0001
Avnieli Velfer Israel 2–18 1027 >95th Males 32.5 41.5 .03 OB 95th, Obesity clinic patients
SO 120%/95th
Females 32.4 46.6 <.001 OB 95th, Obesity clinic patients
SO 120%/95th
Hadjiyannakis Canada 5–17 847 >95th 14 10 9 26 NR Pediatric weight
management
program patients
Stolzman USA 12–17 62 >90th 3 13 NS Community
recruitment
NR, not reported; NS, not significant; OB, obese; OR, odds ratio; OW, overweight; SO, severe obesity.

35
 Two studies reported data from

Community recruitment
clinic 1 population-

clinic 1 population-
Obesity clinic patients

Obesity clinic patients

NHANES, the larger study of which

program patients

Weight management

Weight management

Weight management

Weight management

Weight management
Population Info

(n 5 8579) showed a significant

clinic patients

clinic patients

clinic patients
Pediatric weight
management
increase in prevalence of abnormal

School based
DBP among children with increasing

based

based
Schools
Schools
weight status (overweight and class
III obesity).37,38 For studies that
examined significant differences in
OW: 90th–99th,

OW: 90th–99th,
SO 120%/95th

SO 120%/95th

abnormal DBP across weight

definitions

OB: >99th

OB: >99th
Weight

HW: <90th,

HW: <90th,
categories (13 of 19), 8 showed a
OB 95th,

OB 95th,

significantly higher prevalence of

abnormal DBP among children in a
higher weight category compared
P value includes

P value includes
differences

differences

with children in a lower weight

Notes

category. Among the largest study

by sex

by sex

(n 5 29 286), prevalence increased

from 9.4% in children with healthy
weight to 20.1% in children with
<.001

<.001
<.001

<.001

<.001
<.001
.01

<.05
NR

NR

NR

NR
P

class I obesity.15
Class III

66.8

67.4

69.8

A total of 51 studies examined

120

mean DBP (Table 24); 28 of them

reported significant differences in
Class II

60.1

59.9

64.3
120

116

117

mean DBP by weight status.

Notably, of the population-based
Class I

1.75

1.75

studies, none reported consistently

66.9

53.9

67.4
114.1
116

116

113

higher DBP among those with

obesity. One reported higher DBP
Overweight

1.55

1.24

among females8 and another only

121.0
113.3
110

in 11- to 18-year-old males.50

Studies showing a significant
Healthy

1.23

1.25

difference in DBP by weight

112.8
104.8
106.9
100

status indicated a stepwise

increase in DBP as weight
114.3
105.8
Total

116

increased from healthy weight

HW, healthy weight; NR, not reported; OB, obese; OW, overweight; SO, severe obesity.

to obesity. Only 1 school-based

Subgroup
(eg, M/F)

Females

Females

Females

study included severe obesity,

Males

Males

Males

reporting significantly higher

DBP in children with class II
percentile

percentile

percentile

obesity compared with those

Units
mm Hg

mm Hg

mm Hg

mm Hg

mm Hg
z-score

with class I obesity.22 With the

TABLE 22 Mean Systolic Blood Pressure (n 5 52)

exception of some clinic samples,

62
847

120

154

880
1027

3978

1679

1004

the mean reported DPB was

N

<70 mm Hg, even among children

Median 12
Ages (y)

with obesity.
2–18

5–17

6–11
12–13

12–18

12–17

12–17
2–5

Hypertension
Denmark
Country

An additional 61 studies examined

Canada

Japan
Korea
Israel

the prevalence of hypertension

USA
USA

(Table 25).6,7,9,11–14,16,17,20–23,26,
Hadjiyannakis

29–33,37,40,42,77,78,80–83,92,102,108–137
Avnieli Velfer

All
Kloppenberg
First Author

Stolzman
Sougawa

studies reported on the prevalence

Tsao-Wu

across weight groups, with the

Kim

majority of studies comparing

36 SKINNER et al
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by guest
TABLE 23 Prevalence of Abnormal Diastolic Blood Pressure (n 5 19)
Definition Subgroup Weight
First Author Country Ages (y) N of Abnormal (eg, M/F) Total Healthy Overweight Class I Class II Class III P Definitions Population Info
Ice USA 9–13 29286 >95th 9.4 12.8 20.1 <.01
Davis USA 7–18 211 >90th 4 0 9 NS
Bindler USA 11–14 151 >90th 9.7 22.0 .050
Turconi Italy 14–17 532 >95th Males 4.8 6.1
Females 9.2 6.8
Skinner USA 6–17 NR >95th 1.8 1.4 0.8 4.0 NS NHANES 2001–2002
Simsek Turkey Mean 5 10.8 115 >95th 0 14.7 <.001 OB >97th
Puri USA 10–18 198 >95th 0 4 NS General pediatric and
endocrinology
patients
Skinner USA 3–19 8579 >95th 0.45 1.20 0.60 4.66 .004 NHANES 1999–2012
Maximova Canada 6–19 2087 >75th 6–11 y 20.4 27.6 NR

PEDIATRICS Volume 151, number 2, February 2023

12–19 y 21.9 29.3 NR
Krzyzaniak Poland 10–18 4904 $90th, 3 d Males 7.4 6.5 13.8 29.4 .000
Females 10.1 8.4 16.8 25.4 .000
Stray-Pederson Norway 15–18 2156 >95th 0.4% ref OR 5 1.0 OR 5 5.1
Kim Korea 10–18 1412 >95th 1998 KNHANES 5.4 8.8 13.2 <.05
1158 2001 KNHANES 3.2 3.8 4.1 NS
Botton France 8–17 452 >95th 0.7 2.6 0.31 OW >90th
Harding UK 11–13 6407 >95th Males 5.1 OR 5 1.0 OR 5 2.50 OR 5 5.74 <.05
Females 3.7 OR 5 1.0 OR 5 1.66 OR 5 5.05 <.05
Serap Turkey 6–16 284 >95th Males 1.9 12.4 <.001 Pediatric endocrinology
patients

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Females 2.1 17.5 <.001
Messiah USA 8–14 1698 >90th 8–11 y 3.23 7.59 10.39
12–14 y 4.93 4.56 7.63
Avnieli Velfer Israel 2–18 1027 >95th Males 10.7 18.5 .01 OB 95th, Obesity clinic patients
SO 120%/95th
Females NS OB 95th, Obesity clinic patients
SO 120%/95th
Hadjiyannakis Canada 5–17 847 >95th 8 7 6 10 NR Pediatric weight
management
program patients
Stolzman USA 12–17 62 >90th 3 6 NS Community recruitment
KNHANES, Korean National Health and Nutrition Examination Survey; NR, not reported; NS, not significant ; OB, obese; OR, odds ratio; OW, overweight; SO, severe obesity.

37
 hypertension prevalence between

Community recruitment
clinic 1 population-

clinic 1 population-
Obesity clinic patients

Obesity clinic patients

children of healthy weight and those

program patients

Weight management

Weight management

Weight management

Weight management

Weight management
Population Info

with obesity. Fifteen studies

clinic patients

clinic patients

clinic patients
Pediatric weight
management

School based
reported on prevalence of
hypertension among children and

based

based
Schools
Schools
teenagers with increasing obesity
severity (class I to class III),
whereas 4 studies examined
Weight Definitions

OW: 90th–99th,

OW: 90th–99th,
SO 120%/95th

SO 120%/95th

prevalence of hypertension among

OB: >99th

OB: >99th
HW: <90th,

HW: <90th,
children with healthy weight and
OB 95th,

OB 95th,

overweight. All studies except 133

that examined the association
between hypertension and weight
P value includes

P value includes
differences

differences

group showed significant differences

Notes

in the prevalence of hypertension

by sex

by sex

between weight categories, with

increasing prevalence of
hypertension with increasing weight
.003

.039
<.001

<.001

<.001
<.001
.31

NR

NR

NR

NR
NS
P

category. The studies were

conducted in various countries;
Class III

71.1

60.9

62.9

34 reported US data. The majority of

72

the studies (n 5 37) defined

hypertension as SBP or DBP >95th
Class II

67.5

70.1

56.1

56.8
70

70

percentile for age, biological sex,

and height. Of these studies,
Class I

0.54

0.78

hypertension prevalence for

66.5

67.5

74.1
69.5

51.3

55.6
69

children of healthy weight across

Overweight

age groups ranged from 1% to 14%

0.21

0.5

64.3
65.4

compared with 4% to 30% for

60

children with obesity. As expected,

prevalence was lowest in early
Healthy

0.09

0.40

childhood (4% to 6% for children

59.7
60.3
71.9
60

with healthy weight and 8% for

children with obesity) and highest
Total

60.5
60.8

HW, healthy weight; NR, not reported NS, not significant; OB, obese; SO, severe obesity.
70

among teenagers (2% to 10% for

Subgroup
(eg, M/F)

teenagers with healthy weight and

Females

Females

Females
Males

Males

Males

3% to 39% among teenagers with

obesity). Studies that defined
hypertension as SBP or DBP >90th
mm Hg

mm Hg

mm Hg

mm Hg

mm Hg
z-score
Units
TABLE 24 Mean Diastolic Blood Pressure (n 5 51)

percentile for age, sex, and height

(n 5 13) showed similar prevalence
847

120

154

880
1027

3978

1679

62

1004
N

both for children with healthy

weight (5% to 12%) and those with
Median 12
Ages (y)

obesity (18% to 24%) across all age

2–18

5–17

6–11
12–13

12–18

12–17

12–17
2–5

groups. For studies (n 5 2) with the

large population samples
Denmark

(n > 20 000) of children ages 6 to

Country

Canada

Japan
Korea
Israel

19 years and the most rigorous

USA
USA

definition of hypertension (SBP or

Hadjiyannakis

DBP >95th percentile on 3 repeated

Avnieli Velfer

Kloppenberg
First Author

Stolzman
Sougawa

measures), hypertension prevalence

Tsao-Wu

was 1% for children with healthy

Kim

weight and 5% for children with

38 SKINNER et al
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by guest
by guest
TABLE 25 Prevalence of Hypertension (n 5 61)
Definition Subgroup Weight
First Author Country Ages (y) N of Abnormal (eg, M/F) Total Healthy Overweight Class I Class II Class III P Notes Definitions Population Info

Koebnick USA 6–17 237248 >95th 3 times 2.1 0.9 2.0 3.8 9.2 <.05
King USA 5–18 1121 Assume >90th 5–8 y white 6 20 <.05
5–8 y AA 10 28 <.05
9–12 y white 8 26 <.05
9–12 y AA 14 28 <.05
13–18 y white 12 47 <.05
13–18 y AA 20 38 <.05
Kim Korea 10–19 931 <90th 13.4 11.6 15.9 23.5 .0070
Israeli Israel 16–19 560588 >120/80 Males 56.5 64.7 66.4 <0.01 Army recruitment
exam
Females 34.3 46.9 55.6 0.01
Halley Castillo Mexico 7–24 1366 >90th 8.4% 18.4% <.000 Central Mexican
Ice USA Mean 10.8 23263 >95th 20.0 14.4 20.8 29.8 51.0 <.05
Genovesi Italy 5–11 5131 >95th Males 3.1 0.8 5.8 21.5 <.001
Females 3.8 1.9 5.5 20.1 <.001
Falkner USA 2–19 6331 >95th 2–5 Males 6.2 5.7 6.6 7.8
2–5 Females 4.3 3.4 4.4 7.9
6399 6–10 Males 6.3 4.6 6.6 10.8

PEDIATRICS Volume 151, number 2, February 2023

6–10 Females 6.5 4.3 9.0 11.2
4923 11–15 Males 9.9 6.6 8.8 20.0
11–15 Females 9.5 5.5 7.8 19.8
965 16–19 Males 11.8 9.6 13.3 18.5
16–19 Females 10.1 4.6 16.3 20.8
Gokler Turkey 14–18 3918 >95th Urban 9.7 ref OR 5 2.25 OR 5 3.88 <.05
Rural 2.9 ref OR 5 5.71 OR 5 22.09 <.05
Duncan USA 12–19 991 >90th 8.0 4.4 6.0 25.6 NR NHANES 1999–2000
Cheung USA 10–19 21062 >95th 3 times 1.6 2.6 6.6 <.001
Bloetzer Switzerland Mean 12 5207 >95th 2.2 1.4 3.8 14.9 <.001
Bell Australia 6–13 283 >95th 3.4 7.3 19.0 .012
Bindler USA 11–14 151 >95th 11.7 36.6 .001
Wirix The Netherlands 4–17 1407 >95th 3.5 3.5 7.8

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Turchiano USA 14–18 1185 >90th 11.8 25.6 30.3 <.001 Youth of urban
minoritized groups
Stiefel USA 14–18 7705 >95th 21.2% OR 5 1 aOR 5 2.33 <.05 Student athletes
Skinner USA 6–17 NR >95th 4.8 2.8 5.0 12.6 <.01 NHANES 2001–2002
Propst USA Mean 12.7 1111 >95th 33.2 36.7 .2989 SO >99th Pediatric
endocrinology
patients
Perez USA (Puerto Rico) 12–18 101 >90th 15.1 35.4 .018
Ovbiagele United States 14–21 603 >95th, 140/90 14% 8% 15% 31%
Nguyen USA 3 to 17 691 NHBP 17.5 12 23 25 38 NR
Moore USA 5–17 745 >90th 18.4% aOR 5 1.0 aOR 5 1.87 aOR 5 3.76 <.05
Moore USA 5–17 1829 >95th Males 14.5% OR 5 1.0 aOR 5 2.48 aOR 5 4.33 <.05
Females 13.0% OR 5 1.0 OR 5 1.69 OR 5 4.01 <.05 OB
Marcus USA Mean 11.2 1305 >90th 23.8 37.4 <.0001
Michalsky USA 13–19 242 >95th, 140/90 49.0 38.6 56.6 61.2 <.01 1: BMI 30–50, Bariatric surgery
2: BMI 50–60, patients
3: BMI >60
Mavrakanas Greece 4–10 572 >95th 7.9 4.1 21.1 NR
Meininger USA 1070 >90th 4.7 7.3 19.2 <.05
Yoshinaga Japan 6–12 471 >120–130, Males 10.7 24.9
>70–80
Females 11.7 26.5
Voorhees USA 11–13 426 >90th 12% 1.0 1.2 9.7 <.05 OB Hmong 1 white
patients
Schwandt Germany 3–18 22051 >95th Males 5.7 10.4 18.6
Females 5.0 9.1 24.0
Rivera-Soto USA (Puerto Rico) Mean 8.9 249 >95th 12.6% 7.9% 18.3% <.05
Redonco USA 2–17.9 11348 Physician 1% OR 5 1.0 OR 5 1.0 OR 5 3.5 <.05 OB Patients with type 1
diagnosed diabetes mellitus

39
by guest
40
TABLE 25 Continued
Definition Subgroup Weight
First Author Country Ages (y) N of Abnormal (eg, M/F) Total Healthy Overweight Class I Class II Class III P Notes Definitions Population Info

Menghetti Italy 6–17 2007 >95th 5.5 F, 6.9 M OR 5 1.0 OR 5 4.22 <.05
Li USA 3–19 20905 >95th 3.11 2.06 3.09 5.46 9.85 <.05
Jayawardene USA 12–19 23438 >95th, 140/90 Males 2.5 3.6 8.0 9.7 NR NHANES 1999–2014
Females 2.0 2.9 3.3 8.4 NR
Polat Turkey 7–12 2826 >95th 2.5 10.9 32.8 <.001
Park, S Korea 10–19 1554 >130/85 2.1 6.1 10.8 <.05 2007–2008 KNHANES
Onsuz Turkey 6–15 2166 >95th 9.0% OR 5 1.0 OR 5 1.6 OR 5 2.8 <.05 WHO reference
standards
Laurson USA 12–18.9 3385 Joliffe standards Males 6.6 11.5 22.7 NR NHANES
Females 2.9 2.2 9.0 NR
Bar Dayan Israel 17 76732 >140/90 Males 0.4% 0.2% 0.75% 3.5% 8.3% <.001 Reporting for military
service
Females 0.074% 0.04% 0.08% 0.8% 4.2% <.001
Acosta USA Mean 15.4 1010 >95th 3 times 2.5% OR 5 1 aOR 5 4.88 aOR 5 38.37 <.05
Levin Israel 17 1 021 211 >180/110 Males 0.03 0.26 <.001 Severe Reporting for military
hypertension service
Females 0.03 0.16 .053
Park Korea 12–19 664 130/85 5.3 7.1 16.2 NHANES
Caserta Italy 11–13 646 >90th Males 9.0 13.3 13.2 NS
Females 9.5 10.1 20.7 NS
Marcus USA Mean 11.8 6358 >95th 8.9 9.8 20.3 31.6 <.001
Maldonado Portugal 4–18 5381 >95th 12.8% OR 5 1.0 aOR 5 1.50 aOR 5 1.94 Both <.05
Chiolero Switzerland 6th grade 5207 >95th 11.4% OR 5 1.0 OR 5 2.7 OR 5 12.0 <.001 Both
Del- Rio-Navarro Mexico 6–13 1819 >95th Males 1.7 5.3 10.0 <.05
Females 2.9 7.4 11.2 <.05
Pan USA 12–19 4450 >90th 20.1% 15.8 20.1 33.9 <.05 OB NHANES 1999–2002
Nur Turkey 14–18 1020 >95th repeated 4.4 4.0 18.4 .00
Salvadori Canada 4–17 675 >95th 4.0 13.1 19.5
Adams USA 14–19 4263 $120/80 31.9 61.7 <.0001 Rural population
Fyfe-Johnson USA 8–17 300 >90th percentile 33 8 31 62 Clinic patients
Gunes USA 11–18 363 >95th percentile Males 10.7 24.6 .111 Adolescent clinic
patients

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Females 20.6 29.5 .198 Adolescent clinic
patients
Hadjiyannakis Canada 5–17 847 >95th SBP 4 3 3 7 NR Pediatric weight
or DBP management
program patients
Jackson USA 12–19 2440 AAP Guidelines 4.11 1.88 1.86 5.89 14.7 NR NHANES
Lennerz Germany 14–24 431 >95th 42 55 64 <.001 Weight management
1 some
community
Rodrigues Portugal 6–9 1555 >95th percentile Males 3.1 1.0 (ref) aOR 5 1.26, aOR 5 3.40, Schools
P 5 .69 P 5 .08
>95th percentile Females 4.3 1.0(ref) aOR 5 2.43, aOR 5 5.26, Schools
P 5 .03 P < .01
“High-normal,” Males 3.4 1.0 aOR 5 2.34, aOR 5 6.13, Hypertension in Schools
90th-95th P 5 .09 P < .01 separate
submission
“High–normal,” Females 5.6 1.0(ref) aOR 5 1.28, aOR 5 4.25, Schools
90th–95th P 5 .53 P < .01
Silverio USA 2–17 421 ICD-10 0.93 5.7 .006 Family medicine clinic
patients
Tsao-Wu USA 2–5 154 >95th percentile 0 0 0 NR Weight management
clinic patients
6–11 880 0 1.6 3.4 NR Weight management
clinic patients
12–17 1004 1.6 2.2 7.7 NR Weight management
clinic patients
aOR, adjusted odds ratio; NR, not reported; NS, not significant; OB, obese; OR, odds ratio; OW, overweight; SO, severe obesity.

SKINNER et al
 obesity, increasing to 9% for

Weight management clinic

Weight management clinic

Weight management clinic

Weight management clinic

children with class II obesity.
Population Info

Steatohepatitis clinic
patients 1 some
Liver Function

community
Alanine Aminotransferase

patients

patients

patients

patients
A total of 8 studies examined the
prevalence of abnormal alanine
aminotransferase (ALT),6,34,67,81,83,
104,138,139
Definitions

and 8 provided mean

Weight

values for ALT.6,13,53,54,66,67,70,74

Three additional studies examined the
prevalence of nonalcoholic fatty liver
Notes

disease (NAFLD).5,67,70 The 8 studies

examining the prevalence of
.009
<.001
.082
<.001

.002

.002

NR

NR

NR
abnormal ALT (Table 26) used a
P

range of definitions from >20 U/L to

>40 U/L and each of the 5 studies
Class III

38.2

10.5
6.4

9.0
30

36

used a different cut point. Four

studies found significant differences
Class II

in prevalence of abnormal ALT

41.4

6.4

7.0

7.1
26

31

between children with healthy weight

and children with obesity.6,67,104,139
OR 5 2.51
31.6
16.7
38.1
42.1
0.0

6.9

6.6

6.4
Class I

15

25

Two studies included only children

with obesity; 1 found no significant
difference between class I, II, or III
Overweight

obesity in prevalence of abnormal

22.9
19.7
19.4
9.0

ALT,34 whereas another did.81 Two

13

additional studies did not provide

statistical analysis of prevalence.83,138
OR 5 1.0
3.8

3.9
2.9
3.0
Healthy

Four studies provided mean values

for ALT (Table 27). Three studies
Total

9.0
5.3
14.9

compared mean ALT between

children with healthy weight and
<26 U/L males
>22 U/L females;

children with overweight and

of Abnormal
Definition

obesity and found a significant

>30 U/L

>40 U/L
>32 U/L
>20 U/L
>50 U/L

>80 U/L

difference in mean ALT between

>90th

groups.6,53,54 A study of children

>36

with Down syndrome found no

Subgroup
(eg, M/F)

difference between mean ALT in

Females
Males

children with healthy weight and

Yes
No
No
No
TABLE 26 Prevalence of Abnormal ALT (n 5 8)

children who were overweight.70

Four studies compared mean
226
283
101

496

431

767

154

880
1262

1004
N

ALT in children with overweight

and class I, II, III obesity, and 3
Mean 9.6

Mean 13
Ages (y)

6–13
3–18
8–19

6–11
14–17

14–24

12–17
2–5

found significant differences in

mean ALT between children with
NR, not reported; OR, odds ratio.

overweight and children with

Australia

Australia

Germany
Country

Mexico

obesity.66,67,74
USA

USA

USA

USA

Aspartate Aminotransferase and NAFLD

First Author

Salvatore

A total of 2 studies examined the

Tsao-Wu
Kopping

Lennerz
Purcell
Booth

prevalence of abnormal aspartate

Seth
Bell

aminotransferase (AST),34,138 whereas

PEDIATRICS Volume 151, number 2, February 2023 41

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by guest
 4 provided mean values for AST.53,54,

management program
67,70
Of the 2 studies examining the

Steatohepatitis clinic
Population Info

prevalence of abnormal AST

Patients with Down

Pediatric weight
(Table 28), 1 from a pediatric

School based
syndrome
endocrine clinic found no significant

Community

Community
patients

patients
difference abnormal AST among
children with class I, II, or III obesity.34
The other study did not provide
OW 5 85th–97th %ile,

OW 5 85th–97th %ile,
statistical analysis of prevalence.138
A study of children with Down
definitions
Weight

syndrome showed a significant

OB > 97th

OB > 97th
difference between mean AST
(Table 29) for children with healthy
weight (35.00 U/L) and children with
overweight (30.12 U/L).70 This same
IV 5 26
Notes

study showed almost double the

prevalence of NAFLD (Table 30) in
children who were overweight.
<.002
<.001

.001

<.001
.001
<.05
NR
NS

NS
P

Another study showed no significant

differences by obesity severity for
Class III

mean AST or NAFLD.67 A third study

31.6
30.5
29

64

demonstrated greater prevalence of

NAFLD among those with severe
Class II

25.5

obesity, compared with class I

25

61

obesity.5
Class I
24.90

21.0

Obstructive Sleep Apnea

24

23

17

59

Eight studies examined the prevalence

Overweight

of obstructive sleep apnea (OSA)

21.15

28.74

24.9

(Table 31).5,6,13,83,135,140 By parent

189
17

16

19
41

report, there was no significant

difference in the prevalence of OSA
Healthy
15.94

27.57

among children with healthy weight,

17

16

11

overweight, or obesity.6 Studies using

Total

polysomnography results show

25.0

increasing prevalence of OSA as

obesity severity increases.5,83,140,141
Subgroup
(eg, M/F)

Females
Males

Studies using diagnosis of OSA also

find increased OSA as obesity
worsens.135,142
NR, not reported; NS, not significant; OB, obese; OW, overweight.
Units
UI/L

UI/L

IU/L

IU/L
U/L

U/L

U/L

U/L

Asthma
283

345
847

120
767
2244
84

1332
N

A total of 26 studies reported

the prevalence of asthma
Mean 13
Ages (y)

12–13

(Table 32).135,142–166 Virtually all

6–13
7–20
5–18

6–19
5–17

5–19

studies used parent-reported or

TABLE 27 Mean ALT (n 5 8)

self-reported asthma, although they

Australia
Country

Canada
Canada

Canada

varied in the reporting of current

Korea
Italy
USA

asthma or ever having asthma, as

US

well as specifically asking for report

Hadjiyannakis

of a physician diagnosis. Most

First Author

Zabarsky
Valentini

studies showed significantly higher

Higgins
Salawi

Seth

asthma in children with obesity

Kim
Bell

compared with children healthy

42 SKINNER et al
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by guest
 weight. One nationally although abnormal values were more
Pediatric endocrinology representative US study of children frequently observed in the higher age
Population Info

2 to 19 years of age showed 15.7% categories.

children with obesity had asthma,
compared with 10.3% of children Implications for Lipid Screening
patients

with healthy weight.144 Only In general, prevalence of abnormal

2 studies, both of a health plan lipid values varied with weight
population, included children with classification. For HDL cholesterol,
severe obesity, demonstrating a values decreased as weight
Definitions
Weight

stepwise increase in asthma classification increased, with

incidence and prevalence as weight prevalence of abnormal HDL
status increased.148,149 approximately 10% in children with
Notes

healthy weight and 40% for children

Depression with obesity. There were not enough
A total of 6 studies examined the data to determine whether prevalence
.099
P

prevalence of depression,6,13,81,135, of abnormal HDL varied within the

167,168
whereas 3 provided mean obesity classification by severity.
Class III

values for depression inventories.167,

11.8

Mean HDL values also showed a

169,170
The studies of the prevalence of decrease (worsening) with increasing
depression (Table 33) showed weight classification. Similarly, the
Class II
31.0

conflicting findings. Three, based on prevalence of abnormal LDL

Center for Epidemiologic Studies cholesterol also increased with
Depression Scale (CES-D) scores, self- increasing weight classification.
Class I

0.0
13.3

26.3

report, and International Classification

of Diseases, 10th Revision (ICD-10), The prevalence of abnormal TG
codes showed no difference by weight increased with increasing weight
Overweight

status.81,135,167 Two others, using classification, with the magnitude

11.5
9.7
0

parent report and depression differing depending on the abnormal

inventory, showed significantly higher cutoff value chosen. Mean TG also
depression as weight status increased as weight classification
Healthy

4.3
4.2

increased.6,168 The mean values for increased.

depression inventories (Table 34)
Abnormal total cholesterol values
Total

were more consistent; 2 demonstrated

7.2
4.9

significantly higher scores at higher were more common in children with

weight status,169,170 whereas another obesity than in children with healthy
of Abnormal

weight. There was also a significant

Definition

smaller study examining class III

>33 U/L
>26 U/L

difference in mean total cholesterol

obesity did not.167
>46

between children with healthy weight

and children with obesity. In these
DISCUSSION
Subgroup
(eg, M/F)

studies, a variety of cutoffs for

Females

Overall, across most laboratory values,

Males

abnormal lipid values were used, but

diagnoses, and age groups, obesity was although prevalence varied with the
TABLE 28 Prevalence of Abnormal AST (n 5 2)

associated with increased prevalence cutoffs, having obesity was in all

101

496
N

of abnormal values and/or greater studies associated with a higher

comorbidity prevalence. In addition, prevalence of abnormal lipid levels.
Ages (y)

14–17

more severe degrees of obesity were

3–18

associated with greater abnormalities, Choosing the cutoff point considered

in concordance with prior evidence.38 to be clinically relevant is important
Australia
Country

However, population-based data to understanding the potential

showed smaller differences, compared application of these data. For
US

with samples drawn from clinical care. example, for the studies reporting TG
Additionally, these population-based abnormalities, many studies selected
First Author
Salvatore

samples typically showed that the >110 mg/dL, whereas others selected
Booth

great majority of children have normal >130 mg/dL or >150 mg/dL. The
values, even children with obesity, prevalence varies considerably

PEDIATRICS Volume 151, number 2, February 2023 43

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by guest
 depending on the cut-point selected. response relationship between
Patients with Down syndrome

Steatohepatitis clinic patients

Multiple organizations, including the increasing obesity classification and
National Lipid Association and fasting insulin level, but many studies
Population Info

the Endocrine Society, indicate only compared children with healthy

$150 mg/dL as elevated TG, and weight versus children with obesity,
School based so it is less clear when glucose
Community

Community

other organizations, such as the

American Academy of Pediatrics and metabolism aberrations occur or
the American Heart Association, worsen across specific severities of
indicate that the value depends on obesity.
OW 5 85th–97th %ile,

OW 5 85th–97th %ile,

age. High TG is considered to be

>100 mg/dL for children younger There was a wide range of
definitions
Weight

than 10 years and >130 mg/dL for prevalence of abnormal

OB > 97th

OB > 97th

children 10 years and older. This HbA1c (1% to 17%), abnormal

cutoff is important to understand glucose (0% to 26%), abnormal
patterns of high TG in children, insulin (0% to 80%), elevated
especially when the study samples HOMA-IR (0% to 71%), and
Notes

included both younger and older metabolic syndrome (0% to 41%),

children. An example of the effect of depending on the weight status and
0.004

age range of the sample and the

0.03

0.16
NS

NS

the cutoff value used on prevalence

P

definition used to classify abnormal

differences can be seen by 2 studies
values. Surprisingly, there were few
Class III

conducted by Ice et al. When

37

studies reporting prevalence of

conducting their study with a large
prediabetes (1 study) or overt
sample of children ages 9 to 13 years
diabetes mellitus (6 studies) in this
Class II

and using the cutoff of >110 mg/dL,

35

age range. There was great variability

the prevalence of high TG was 14.2%
of mean glucose-related values within
(healthy weight), 29.8% (overweight),
Class I

samples. However, for the most part,

25

23

35

and 49.1% (obese). However, in their

the reported subgroups did not have a
other study with a large sample size
majority of participants classified as
Overweight

of children with a mean age of 10.8

abnormal, nor did the subgroups have
30.12

and the cut-point of >150 mg/dL, the

20.5
24

23

29

a mean glucose or glucose-related

prevalence of abnormal TG was 4.4%
value outside of the healthy range. An
(healthy weight), 12.4% (overweight),
exception is a sample of Canadian
Healthy
35.00

and 25% (obese). There were not

youth ages 9 to 16 years with obesity
26

23

18

enough data to determine whether that had an 80% prevalence of

the prevalence of abnormal values abnormal insulin, and 71% of
Total

varied within the classification of adolescents with class III obesity

obesity. entering a bariatric surgery
Subgroup
(eg, M/F)

Females

program had abnormal HOMA-IR.26

Males

Implications for Glucose Screening

No

The samples with higher prevalence

Most of the studies that reported and higher abnormal values were
Units

prevalence or mean values related to

UI/L

IU/L

typically clinic-based, including

U/L

U/L

glucose metabolism observed that from subspecialist clinics and/or

children and adolescents with obesity
120
767
84
1332

weight management specialty clinics,

N

had a multifold higher prevalence of

NS, not significant; OB, obese; OW, overweight.

including a bariatric surgery program.

abnormal glucose, insulin, and other
Mean 13
Ages (y)

Among these more advanced cases of

12–13
5–18
5–19

glucose-related values compared with obesity, elevated insulin level was

TABLE 29 Mean AST (n 5 4)

children of healthy weight. These consistently high and was not

differences by weight status were
Country

differentiated by class of obesity.

Canada

Korea

reported in preschool-aged children

Italy

USA

up to adolescents. However, there There were no consistent sex

was limited information on the extent differences in glucose-related
First Author
Valentini

to which glucose and related measures. In general, glucose

Higgins

Seth

measures varied across categories of abnormalities increased in

Kim

obesity. A few studies noted a dose- prevalence with increasing age,

44 SKINNER et al
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 although there were noticeable children with obesity. Two studies
Patients with Down syndrome
Steatohepatitis clinic patients
elevations by obesity status in examined prevalence within obesity
samples as young as preschool-aged classifications and found no
Population Info

Obesity clinic patients

Obesity clinic patients

children. There was a dearth of difference in prevalence. Differences
prevalence data available on in mean ALT were found between
nationally representative datasets, children with normal weight and
particularly for HOMA-IR. The those with obesity in addition to
presence of glucose abnormalities increases in mean ALT with
among youth with obesity supports increasing obesity classification.
SO 120%/95th

SO 120%/95th

the need for screening, but given

Definitions

One study of mean AST did not find

Weight

the wide variability observed across

any difference within obesity
OB 95th,

OB 95th,

population and clinic-based studies,

taking into account other risk classification. Only 1 study
factors may be important to avoid documented prevalence of NAFLD,
Notes

unnecessary tests. pointing to an important area of

future research, particularly because
<.001

<.001

Implications for Blood Pressure this study observed a doubled

.13
P

Screening prevalence of NAFLD in children with

overweight compared with children
Class III

The prevalence of elevated SBP was

30

higher in children with overweight with normal weight. Further, only

and obesity compared with children 1 study reported prevalence of OSA.
Class II

With so few data, it is difficult to

19.7

18.6

with healthy weight. This association

27

was true in both males and females. make screening recommendations.

Class I

Mean values of SBP were significantly

4.1

4.9

Asthma is consistently associated

22

different between children with

with obesity in children at a variety
healthy weight and children with
Overweight

of ages. In contrast to the previously

overweight and obesity. Within the
82
20

discussed comorbidities, however,

obesity classification, mean SBP
asthma presents symptomatically.
increased with increasing BMI. The
Healthy

association between SBP and BMI was Therefore, it is unclear whether the
45

observed in all age groups study and data demonstrate a need for
in both males and females. DBP
Total

increased asthma screening.

64.3

prevalence also varied with BMI

across age groups and increased
Sonographic evidence

Data regarding the relationship

of fatty infiltration
Stiffness >2.71 kPa

within increasing obesity between obesity and depression are

of Abnormal
Definition

classifications. Hypertension (defined particularly limited.

as elevated SBP or DBP) prevalence
Diagnosis

increased with increasing BMI. These data suggest there may be a

Prevalence also increased with age. relationship between obesity
depression but are not adequate to
Subgroup
(eg, M/F)

Females

The association of increased make statements regarding the need

Males

prevalence of SBP, DBP, and for screening, specifically for

No

hypertension in children in children children with obesity. All children

767
84

1027
TABLE 30 Prevalence of NAFLD (n 5 3)

with overweight and obesity in 12 years and older should be

addition to increased mean SBP and screened for depression, regardless
Mean 13
Ages (y)
5–18

2–18

DBP supports BP screening these of weight status.171

groups.
Limitations of Current Research
OB, obese; SO, severe obesity.
Country

Implications for Other Screening

Israel

There are several limitations of the

Italy
US

There are a limited number of current literature that warrant

Avnieli Velfer

studies examining prevalence of attention. First, the cross-sectional

First Author

abnormal AST and ALT. Increases in

Valentini

design of these studies prevented an

prevalence were found between examination of within-individual
Seth

children with healthy weight and changes in comorbidity prevalence as

PEDIATRICS Volume 151, number 2, February 2023 45

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by guest
 it relates to fat accumulation and

Family medicine clinic

Obesity clinic patients

Obesity clinic patients

obesity and comorbidity incidence

program patients

Weight management

Weight management

Weight management
Population Info

Population based

clinic patients

clinic patients

clinic patients
Population-based
across the age range. This

Pediatric weight
management
Overweight 90th, Clinic patients

limitation makes it difficult for a

patients
primary care provider to determine
when during a young patient’s life
these screenings are most efficient,
SO 120%/95th

SO 120%/95th

useful, and necessary. Many studies

obesity 99th
definitions

examined samples with wide age

Weight

OB 95th,

OB 95th,

ranges and did not stratify by age

group, making it difficult to identify
a window of opportunity when
Notes

screening may be most useful for

early detection of a patient’s
OW 5 .101,
OB <.001

transition into pathophysiology.

.0002

<.001

<.001

NR

NR

NR

NR
<.05

.05
P

Further, although there were

distinct differences in prevalence of
Class II Class III

abnormalities and mean laboratory

12.8

11.4

13.6
17

values between children with

normal weight versus those who
8.5

5.4

4.4
17.3

13.9

were overweight and obese, more

8

information is needed on the

1.0 (ref) aOR 5 2.00 aOR 5 2.75

aOR 5 2.50

specific amount of body fat or level

Class I

1.3

2.8

3.4

1.7

4.4

of BMI at which aberrations occur.

4
41

Although screening youth with

severe obesity may be commonly
Overweight

practiced, we currently have too

44.6

AHI, Apnea-Hypopnea Index; aOR, adjusted odds ratio; NR, not reported; OB, obese; OW, overweight; SO, severe obesity.

few data to determine whether

youth in the overweight range or at
1.0 (ref)
Healthy

the low end of obesity should be

0.46

screened.
9.1
Total

The inconsistency in definitions of

9

comorbidities is also challenging in

(3 y following BMI)

this age range. It is difficult to

of Abnormal
Apnea–Hypopnea
Definition

compare prevalence estimates when

Persistent SDB

Chart review
Index $2

studies use different thresholds for a

over 8 y

Diagnosis

clinically abnormal or pathologic

AHI >1

AHI >1
ICD-10
TABLE 31 Prevalence of obstructive sleep apnea (n 5 8)

level. Further, it is challenging for

the primary care provider to
Subgroup
(eg, M/F)

Females

develop treatment strategies

1027 Males

without more concrete guidelines on

how to interpret screening results.
9443

1004
172

421

847

421

154

880
N

The inconsistency in definitions

made it difficult to compare
Ages (y)
7–18

2–18

5–12

5–17

2–17

6–11

12–17
5–8

2–5

prevalence across countries, across

race and ethnic groups, and across a
Denmark
Country

variety of settings. There are

Hadjiyannakis Canada
Israel

insufficient data on national

US

US

US
UK

prevalence estimates, with many

Avnieli Velfer

studies using convenience samples

First Author
Andersen

via school-based screening or

Tsao-Wu
Silverio
Kelly

specialty clinical settings. Less is

Frye

known about the occurrence of

46 SKINNER et al
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by guest
by guest
TABLE 32 Prevalence of Asthma (n 5 26)
Definition Subgroup Weight
First Author Country Ages (y) N of Abnormal (eg, M/F) Total Healthy Overweight Class I Class II Class III P Notes Definitions Population Info
Guibas Greece 2–5, 9–13 1622 Physician diagnosis 2–5 y 10.5 1.0 OR 5 1.29 OR 5 1.54 NS
2015 Physician diagnosis 9–13 y 13.5 OR 5 1.0 OR 5 1.45 OR 5 1.69 <.05
Gilliland US 7–18 3792 Physician diagnosis Males IR 5 20.0/1000 IR 5 25.2/1000 IR 5 36.6/1000
Physician diagnosis Females 25.2/1000 34.5/1000 25.6/1000
Black US 6–19 623358 Incident physician IR 18.1/1000 1 aHR 5 1.16 aHR 5 1.23 aHR 5 1.37 <.001 Kaiser
diagnosis
Bibi Israel 2nd grade 5984 Parent report of physician Males 7 14.6 <.001
diagnosis
Females 5.8 10.1 <.05
Vasquez-Nava Mexico 4–5 1160 Parent report of diagnosis 4.7% 7.3% 5.4% NR
Wickens New Zealand 11–12 3052 Parent report ever asthma OR: 1.0 (ref) OR: 1.08 OR: 1.39 .08
Saha US 5–18 2544 Physician diagnosis Males 23% 22.8% 31.9% <.001
Females 12.6% 21.8% 21.3% <.001
Noonan US 9–22 1852 Parent report current 9.5% 7.1 12.1 11.6 <.05 Northern Plains American
asthma Indian patients
Sybilski Poland 6–7, 4510 Physician diagnosis 6–7 y 11.44 1.00 (ref) OR 5 1.99 OR 5 2.17 <.05
13–14
4721 13–14 y 11.36 1.00 (ref) OR 5 1.43 OR 5 0.57 NS
Lu US 12–19 4828 Parent report current Males 6.5% aOR 5 1.0 aOR 5 0.90 NS NHANES sample

PEDIATRICS Volume 151, number 2, February 2023

asthma
Females 8.5% aOR 5 1.0 aOR 5 1.73 <.05
James Australia 4–6 18999 Parent report current 13.11% OR 5 1.0 1.29 1.29 <.05
asthma
Black US 6–19 681122 Physician diagnosis 10.9 1.00 (ref) 1.220 1.367 1.682 <.001 Kaiser
Bedolla-Barajas Mexico 15–18 1600 Incidence of asthma 7.5 9.7 6.5 NS
Alvarez-Zallo Spain 6–7, 3360 Parent report ever asthma 6–7 y 9.8 OR 5 1.0 OR 5 1.14 OR 5 2.29 <.05 OB
13–14
5247 13–14 y 10.4 OR 5 1.0 OR 5 1.14 OR 5 1.18 NS
Akinbami US 2–19 9437 Parent report current NHANES 1998–1994 7.3 6.3 8.4 13.4 .03 1988–1994
asthma
6112 NHANES 2011–2014 10.9 10.3 8.2 15.7 .001 2011–2014 sample
Tai Australia 4–5 1509 Parent report current Males 19.2 29.9 37.1 .005
asthma
Females 15.3 15.2 37.5 <.001

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Yoo Korea 15–17 717 Parent report current Males 6.9% 9.5% .285
asthma
Females 3.7% 3.6% .973
Kwon US 2–11 853 Parent-report asthma Males 19.1 24.3 34.8 .014 Black and Hispanic
diagnosis plus self- patients
report
Females 16.4 33.3 27.3 .005
Musaad US 5–18 1123 Moderate or severe 38.17 40.69 NS HW: 25th–85th
physician diagnosis
Cibella Italy 10–16 708 Self-report asthma 11.9 10.3 21.0 .0008
Akinbami US 2–19 40644 Parent report 7.1–10.3 1.0 1.2 1.7 NHANES 1988-2014
(across years)
Karachaliou Greece Parent report of any 29.7 33.2 <.001 Schools
asthma symptoms
Kelly UK 5–8 9443 Diagnosis (3 y following 1.0 (ref) aOR 5 1.46 <.05 Population based
BMI)
Linthavong US 10 871 Physician diagnosis 34 44 55 <.05 Former extremely low
gestational age
neonates
Machluf Israel 16–19 113671 Mild asthma from medical Males 1.0 (ref) aOR 5 1.61 <.001 Military conscripts
history
Females 1.0 (ref) aOR 5 1.54 <.05 Military conscripts
Machluf Israel 16–19 113671 Moderate-severe asthma Males 1.0 (ref) aOR 5 1.63 <.001 Military conscripts
from medical history
Females 1.0 (ref) aOR 5 1.21 aOR 5 1.54 <.05 Military conscripts
Silverio US 2–17 421 ICD-10 26.7 27.8 .79 Family medicine clinic
patients
aHR, adjusted hazard ratio; aOR, adjusted odds ratio; HW, healthy weight; IR, incidence rate; NR, not reported; NS, not significant; OB, obese; OR, odds ratio.

47
 obesity comorbidities in primary

Adolescents at risk
Pediatric weight management

for depression
Population Info
care settings as detected by

Weight management clinic

providers. The utilization of large
Population Info

Family medicine clinic

Primary care patients

electronic medical record databases
program patients

patients 1 some
may be an efficient remedy to this

community
lack of data.

patients

Definitions
Weight
CONCLUSIONS
Overall, across most laboratory
Definitions

values and diagnoses, obesity was

Weight

Notes
associated with higher mean values
and/or greater comorbidity
prevalence. However, population-
Notes

.007
.10

<.05
based data showed smaller
P
differences, compared with samples
.001

.026
1.00

.99

.97

drawn from clinical care.

P

Class III
NR

14.0
Additionally, these population-based
samples typically showed that the
Class III
9.8

great majority of children have

12

11

Class II

normal values, even children with

Class II

obesity.
13

10

CESD, Center for Epidemiologic Studies Depression Scale; CDI, Children's Depression Inventory; DAWBA, Development and Well-Being Assessment.
Class I

0.73

ACKNOWLEDGMENT
12.1
Class I

18.8

2.4

We thank Chelsea Kracht, PhD, for

11
6

her help in reviewing abstracts.

Overweight
Overweight

0.65

10.3
8.95

42.7

ABBREVIATIONS
Healthy
Healthy

ALT: alanine aminotransferase

0.55
9.8
1.0

2.3

23.6

11.9

10.2
BSI, Brief Symptom Inventory; CESD, Center for Epidemiologic Studied Depression Scale; NR, not reported.

AST: aspartate aminotransferase

ATP: Adult Treatment Panel
Total
9.8

Total

CDC: Centers for Disease Control

NR
10

and Prevention
BSI Depression

DBP: diastolic blood pressure

Parent report
of Abnormal

Self-reported
Chart review

Subgroup
Definition

(eg, M/F)
High CESD

HbA1c: hemoglobin A1c

ICD-10

HDL: high-density lipoprotein

HOMA-IR: homeostatic model
assessment for insulin
DAWBA
Units
Subgroup
(eg, M/F)

CESD

CDI

resistance
IDF: International Diabetes
4845

1490
102

Foundation
N
102
283
847

431

421

165
TABLE 33 Prevalence of Depression (n 5 6)

KQ: key question

TABLE 34 Mean Depression Score (n 5 3)

LDL: low-density lipoprotein

Grade 7–12

Grade 7–12

Grade 7–12
Ages (y)

Ages (y)

NCEP: National Cholesterol

11–17
6–13
5–17

2–17
14–24

12–18

Education Program
NHANES: National Health and
Nutrition Examination
Australia

Germany
Country

Canada

Country

Canada
Turkey

Survey
USA

USA

USA
UK

OSA: obstructive sleep apnea

SBP: systolic blood pressure
Hadjiyannakis
First Author

First Author

Hammerton

TG: triglycerides
Goodman

Goodman

Goldfield
Lennerz

Silverio

WHO: World Health Organization

Bell

Tas

48 SKINNER et al
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 taking into account individual circumstances, may be appropriate.
All technical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or
before that time.
DOI: https://doi.org/10.1542/peds.2022-060643
Address correspondence to Asheley C. Skinner, PhD. E-mail: [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2023 by the American Academy of Pediatrics
FUNDING: Some support for the technical report came from the Strengthening Public Health Systems and Services QT18-1802 through the National
Partnerships to Improve and Protect the Nation's Health grant from the Centers for Disease Control and Prevention.
FINANCIAL/POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
COMPANION PAPERS: Companions to this article can be found at http://www.pediatrics.org/cgi/doi/10.1542/peds.2022-060640, http://www.pediatrics.org/cgi/
doi/10.1542/peds.2022-060641, and http://www.pediatrics.org/cgi/doi/10.1542/peds.2022-060642.

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