Insulin sensitivity, VO2max and body composition in severely obese Swedish children and adolescents

Aim: The aim of this study was to identify relationships between insulin sensitivity (SI), cardiorespiratory fitness and body composition in severely obese Swedish children and adolescents.
Methods: Two hundred and twenty-eight obese children (119 girls, 8–16 years, body mass index (BMI) 23.2–57.0 kg/m²) performed a frequently sampled intravenous glucose tolerance test (FSIVGTT), a submaximal bicycle ergometry test and a dual-energy X-ray absorptiometry (DEXA).
Results: Mean SI (SD) was 0.38 (0.32) (×10⁻⁵/min/pM). SI correlated positively with relative body mass (BM) VO₂max (r = 0.42) (p < 0.001), relative fat-free mass (FFM) VO₂max (r = 0.36) (p < 0.001) and negatively with body mass index standard deviation score (BMI SDS) (r =−0.22) (p = 0.001). SI did not correlate with percent body fat (r =−0.01) and absolute VO₂max (r = 0.01). In multiple regression analyses with SI as dependent variable, VO₂max and body composition, together with gender, age and Tanner stage, explained 20–26% of the variance.
Conclusion: Relative (BM) VO₂max and relative (FFM) VO₂max were stronger predictors of SI than percent body fat in severely obese children and adolescents. The study confirms that cardiorespiratory fitness is of importance for the metabolic syndrome in the studied population. Efforts to improve SI should include physical activity targeting cardiorespiratory fitness also in severely obese children and adolescents.     

Gas exchange during exercise in obese children

Twenty-three obese children, aged 9 to 14 years, ranging in percentage overweight from 26% to 83% (median 51.6%±16.3%), and 37 normal-weight children, matched for sex, age and height, performed a maximal exercise test on a treadmill. Cardiorespiratory performance was assessed by determination of the ventilatory anaerobic threshold (VAT) expressed in ml O₂/min per kg and as a percent of maximal oxygen uptake (% VO₂max). VAT and VO₂max related to body weight were significantly lower (P<0.01) in the obese than in the normal-weight children. VAT % VO₂max was similar in the two groups. A significant correlation was found between VAT and VO₂max both in the obese (r=0.85) and in the control groups (r=0.79). The habitual level of physical activity was lower in the obese subjects compared to the control subjects (P<0.001). In conclusion our study shows that physical fitness of overweight children is quantitatively lowered and that it can be assessed by VAT. VAT does not require a maximal test and is particularly useful in the ergometric study of subjects with exercise intolerance.Abbreviations AT anaerobic threshold - HR heart rate - VAT ventilatory anaerobic threshold - VCO₂ carbon dioxide output - VE ventilation - VO₂ oxygen uptake - VO₂max maximal oxygen uptake     

Ethnic differences in metabolic syndrome among overweight and obese children and adolescents: the Oslo Adiposity Intervention Study

Aim: Are there differences in the prevalence of metabolic syndrome between obese and overweight Norwegian and immigrant children and adolescents? Methods: Two hundred and three overweight and obese Norwegian, Pakistani, Tamil and Turkish patients aged 6–17 years living in Norway were included. Metabolic syndrome was defined as the presence of at least three abnormal values of waist circumference, blood pressure, fasting triglycerides, fasting glucose and HDL cholesterol. Results: The prevalence of metabolic syndrome was significantly higher among the immigrant compared to Norwegian subjects when adjusted for age, gender and BMI‐Z‐score (20.8 vs. 30.6%; OR = 2.2, 95% CI = 1.05–4.77). The prevalence of metabolic syndrome increased with increasing severity of obesity and reached 50% in severely obese immigrants and 30% in severely obese Norwegians. Among the overweight subjects metabolic syndrome prevalence was 23.5% among immigrants and 19.4% among Norwegians. Conclusion: Metabolic syndrome was found more frequently among children and adolescents with Middle Eastern and South Asian origins than Norwegians. Differences were found even after adjustment for age, sex and degree of obesity. This suggests that ethnic minorities may have an increased sensitivity to adiposity and need more aggressive prevention and treatment than their Norwegian counterparts.     

Self-esteem in a clinical sample of morbidly obese children and adolescents

Aim: To study self-esteem in clinical sample of obese children and adolescents.
Methods: Obese children and adolescents aged 8–19 years (n = 107, mean age 13.2 years, mean BMI 32.5 [range 22.3–50.6], mean BMI z-score 3.22 [range 2.19–4.79]; 50 boys and 57 girls) were referred for treatment of primary obesity. Self-esteem was measured with a validated psychological test with five subscales: physical characteristics, talents and skills, psychological well-being, relations with the family and relations with others. A linear mixed effect model used the factors gender and adolescence group, and the continuous covariates: BMI z-scores, and BMI for the parents as fixed effects and subjects as random effects.
Results: Age and gender, but neither the child's BMI z-score nor the BMI of the parents were significant covariates. Self-esteem decreased (p < 0.01) with age on the global scale as well as on the subscales, and was below the normal level in higher ages in both genders. Girls had significantly lower self-esteem on the global scale (p = 0.04) and on the two subscales physical characteristics (p < 0.01) and psychological well-being (p < 0.01).
Conclusion: Self-esteem is lower in girls and decreases with age. In treatment settings special attention should be paid to adolescent girls.     

肥胖儿童青少年血清脂肪因子与其代谢特征的相关性研究

目的 探讨肥胖儿童青少年血清脂肪因子瘦素、脂联素、神经调节蛋白4(Nrg4)及锌α-2糖蛋白(ZAG)与肥胖及代谢的关系。方法 选取在南京医科大学附属儿童医院儿童保健科就诊的5~14岁肥胖儿童。测量身高、体重、腰围、体脂百分比(FM%)、血压、腰围身高比(WHtR)和体重指数标准差(BMISDS);测定ALT、AST及糖脂代谢指标;根据血压及糖脂代谢,将肥胖儿童分为代谢不健康型肥胖(MUO)和代谢健康型肥胖(MHO)。酶联免疫吸附法测定血清脂肪因子水平。结果 192例肥胖儿童(男138名)纳入分析,平均年龄(10.59±1.93)岁,平均BMISDS 2.86(2.38,3.26)。肥胖儿童中检出MUO 164例(85.4%),MHO 28例。校正年龄后,MUO组血清脂联素、Nrg4水平低于MHO组(P<0.05),两组瘦素、ZAG差异无统计学意义。相关性分析显示,MUO组血清瘦素水平与 BMISDS、FM%、WHtR呈正相关(P<0.05);脂联素与年龄、ALT、AST及胰岛素抵抗指数(HOMA-IR)呈负相关(P<0.05);Nrg4与BMISDS、WHtR、ALT、AST呈负相关(P<0.05);ZAG与FM%呈负相关(P<0.05)。logistic回归分析显示,脂联素和Nrg4是肥胖儿童代谢保护因子;ROC曲线显示,脂联素与Nrg4评估肥胖儿童代谢风险的界值点分别为5.56 μg·mL^-1和5.5 ng·mL^-1。结论 肥胖合并代谢紊乱的儿童青少年血清瘦素、ZAG 水平与体脂含量密切相关,而脂联素、Nrg4水平与代谢紊乱程度相关。这些脂肪因子对于识别和干预肥胖儿童青少年代谢紊乱的发生发展具有重要意义。     

不同肥胖程度儿童罹患心血管代谢异常风险的横断面调查

目的 通过对肥胖学生健康评估体检,了解不同肥胖程度儿童青少年罹患高血压、高血糖和血脂异常等心血管代谢异常风险现况。方法 采用现况调查方法,对北京市西城区、海淀区和密云县17所中小学2012至2013年度参加学校常规年度体检并以BMI为评价指标筛查为肥胖的学生,进行以健康风险评估为目的的临床体检,体检内容包括体量（身高、体重及体质成分）,血压,空腹血糖,血脂（总胆固醇、三酰甘油、高密度脂蛋白和低密度脂蛋白）等指标。采用中国肥胖问题工作组（WGOC）制定的BMI超重、肥胖筛查标准判定肥胖状态;采用中国儿童青少年血压参照标准评定儿童高血压;采用儿童青少年血脂异常防治专家共识推荐的中国2岁以上儿童青少年血脂异常诊断标准判断血脂异常;以空腹血糖作为评价指标,采用美国糖尿病联盟推荐糖尿病诊断和分类标准进行评价。结果 1 809/3 227名(56.1%)肥胖学龄儿童青少年完成了现况调查且具有完整体检数据,平均年龄12.2岁。肥胖学生心血管代谢异常指标检出率分别为：高血压30.8%,血脂异常43.3%,糖尿病和空腹血糖受损66.6%,肝功能异常11.6%,脂肪肝16.0%,黑棘皮症21.9%。肥胖男生高血压、空腹血糖受损、肝功能异常、脂肪肝和2项及以上心血管代谢异常检出率均高于肥胖女生。重度肥胖占总肥胖人数的29.9%,协方差分析调整年龄和性别后,重度肥胖学生高血压、肝功能异常、脂肪肝、黑棘皮症和2项及以上心血管代谢异常检出率均高于轻中度肥胖学生。结论 肥胖儿童青少年高血压、高血糖和血脂代谢紊乱等心血管代谢异常高发,心血管代谢异常随肥胖程度增加呈上升趋势;儿童肥胖相关心血管代谢异常高发需要得到更广泛关注。     

肥胖儿童青少年血清脂肪因子与其代谢特征的相关性研究

目的 探讨肥胖儿童青少年血清脂肪因子瘦素、脂联素、神经调节蛋白4(Nrg4)及锌α-2糖蛋白(ZAG)与肥胖及代谢的关系。方法 选取在南京医科大学附属儿童医院儿童保健科就诊的5~14岁肥胖儿童。测量身高、体重、腰围、体脂百分比(FM%)、血压、腰围身高比(WHtR)和体重指数标准差(BMISDS);测定ALT、AST及糖脂代谢指标;根据血压及糖脂代谢,将肥胖儿童分为代谢不健康型肥胖(MUO)和代谢健康型肥胖(MHO)。酶联免疫吸附法测定血清脂肪因子水平。结果 192例肥胖儿童(男138名)纳入分析,平均年龄(10.59±1.93)岁,平均BMISDS 2.86(2.38,3.26)。肥胖儿童中检出MUO 164例(85.4%),MHO 28例。校正年龄后,MUO组血清脂联素、Nrg4水平低于MHO组(P<0.05),两组瘦素、ZAG差异无统计学意义。相关性分析显示,MUO组血清瘦素水平与 BMISDS、FM%、WHtR呈正相关(P<0.05);脂联素与年龄、ALT、AST及胰岛素抵抗指数(HOMA-IR)呈负相关(P<0.05);Nrg4与BMISDS、WHtR、ALT、AST呈负相关(P<0.05);ZAG与FM%呈负相关(P<0.05)。logistic回归分析显示,脂联素和Nrg4是肥胖儿童代谢保护因子;ROC曲线显示,脂联素与Nrg4评估肥胖儿童代谢风险的界值点分别为5.56 μg·mL^-1和5.5 ng·mL^-1。结论 肥胖合并代谢紊乱的儿童青少年血清瘦素、ZAG 水平与体脂含量密切相关,而脂联素、Nrg4水平与代谢紊乱程度相关。这些脂肪因子对于识别和干预肥胖儿童青少年代谢紊乱的发生发展具有重要意义。     

Healthy active living: Physical activity guidelines for children and adolescents

The epidemic of childhood obesity is rising globally. Although the risk factors for obesity are multifactorial, many are related to lifestyle and may be amenable to intervention. These factors include sedentary time and non-exercise activity thermogenesis, as well as the frequency, intensity, amounts and types of physical activity. Front-line health care practitioners are ideally suited to monitor children, adolescents and their families’ physical activity levels, to evaluate lifestyle choices and to offer appropriate counselling.This statement presents guidelines for reducing sedentary time and for increasing the level of physical activity in the paediatric population. Developmentally appropriate physical activity recommendations for infants, toddlers, preschoolers, children and adolescents are provided. Advocacy strategies for promoting healthy active living at the local, municipal, provincial/territorial and federal levels are included.     

Trends in body mass in Swedish adolescents between 2001 and 2007

Aim: (1) Compare BMI standard deviation scores (BMIsds) in 16-year olds in 2001 and 2007 to assess trends. (2) Describe tracking of BMIsds between ages 10 and 16 years, in a longitudinal 6-year follow-up. (3) Identify possible predictors in 2001 for high BMIsds in 2007 and increase in BMIsds between 2001 and 2007.
Methods: A six-year follow-up study on 296 subjects, aged 10 years at baseline and a panel study among 16-year olds. BMIsds was used as the main outcome.
Results. No difference in BMIsds in 16-year-old adolescents was found between 2001 and 2007. Strong tracking (r = 0.80, 95% CI: 0.75–0.84) was found for BMIsds between ages 10 and 16 years. Low aerobic capacity and high BMIsds at age 10 years predicted overweight at age 16 years. High BMIsds in 2001 predicted a decline in BMIsds (OR: 0.58, 95% CI: 0.43–0.76) and high level of self-reported moderate-to-vigorous physical activity predicted an increased BMIsds (OR: 1.38, 95% CI: 1.13–1.67).
Conclusion: There was no difference in prevalence of overweight plus obesity between the 2001 and 2007 samples. Normal weight and good aerobic fitness in 10-year-old children seems to decrease the risk of elevated relative BMI in 16-year olds.     

Antiphospholipid antibodies and lipoprotein(a) in obese children

Aim: Antiphospholipid (aPL) antibodies, Lipoprotein(a) [Lp(a)] and obesity are considered three independent risk factors for development of cardiovascular diseases. We investigate the presence of aPL antibodies and the Lp(a) concentration in 190 obese and 30 healthy children divided into prepubertal and pubertal, compared with healthy adults.
Results: aPL antibodies were detected in 2.65% of prepubertal and in 2.59% of pubertal obese children. Considering results obtained by Lp(a) test, 4.4% of prepubertal and 5.2% of pubertal obese children and 17.5% of healthy adults were at risk for development of cardiovascular diseases.
Conclusion: The presence of various prothrombotic risk factors increases the probability of developing thrombosis. Considering aPL antibodies there is no statistically significant difference among the different considered groups; therefore each category has the same risk factor. The Lp(a) distribution in adults is significantly different from the Lp(a) distribution in prepubertal (p = 0.012) and pubertal (p = 0.029) obese children. There is no significant difference among prepubertal subjects (p = 0.632) as well as pubertal subjects (p = 0.465), independently from the BMI. These results suggest the control of BMI in young population to avoid the presence of the obesity as another independent prothrombotic risk factor to be added to aPL and Lp(a) in the future adulthood.     

Repetitiveness of the oral glucose tolerance test in children and adolescents

BACKGROUNDData regarding the most suitable diagnostic method for the diagnosis of glucose impairment in asymptomatic children and adolescents are inconclusive. Furthermore, limited data are available on the reproducibility of the oral glucose tolerance test (OGTT) in children and adolescents who are obese (OB).AIMTo investigate the usefulness of the OGTT as a screening method for glucose dysregulation in children and adolescents.METHODSEighty-one children and adolescents, 41 females, either overweight (OW), OB or normal weight (NW) but with a strong positive family history of type 2 diabetes mellitus (T2DM), were enrolled in the present observational study from the Outpatient Clinic of Paediatric Endocrinology of the University Hospital of Patras in Greece. One or two 3-h OGTTs were performed and glucose, insulin and C-peptide concentrations were measured at several time points (t = 0 min, t = 15 min, t = 30 min, t = 60 min, t = 90 min, t = 120 min, t = 180 min).RESULTSGood repetitiveness was observed in the OGTT response with regard to T2DM, while low repetitiveness was noted in the OGTT response with regard to impaired glucose tolerance (IGT) and no repetitiveness with regard to impaired fasting glucose (IFG). In addition, no concordance was observed between IFG and IGT. During the 1^st and 2^nd OGTTs, no significant difference was found in the glucose concentrations between NW, OW and OB patients, whereas insulin and C-peptide concentrations were higher in OW and OB compared to NW patients at several time points during the OGTTs. Also, OW and OB patients showed a worsening insulin and C-peptide response during the 2^nd OGTT as compared to the 1^st OGTT.CONCLUSIONIn mild or moderate disorders of glucose metabolism, such as IFG and IGT, a diagnosis may not be reached using only one OGTT, and a second test or additional investigations may be needed. When glucose metabolism is profoundly impaired, as in T2DM, one OGTT is probably more reliable and adequate for establishing the diagnosis. Excessive weight and/or a positive family history of T2DM possibly affect the insulin and C-peptide response in the OGTT from a young age.     

肥胖儿童及青少年脂代谢紊乱与早期血管病变的关系

目的 了解肥胖儿童青少年的脂代谢紊乱、血压与血管内膜中层厚度(IMT)变化.方法 2008年1月-2009年9月,从浙江省3家医院共募集580例7～17岁肥胖儿童青少年,按照血脂水平分为2组:血脂正常组中,男100例、女52例,平均年龄10.47岁;血脂紊乱组中,男305例、女123例,平均年龄10.83岁.分别进行相关体格检查,计算体质指数(BMI),检测血脂、血糖、血胰岛素和肝酶等生化指标,并对其中1家医院的285例研究对象进行颈动脉IMT检测.结果 (1)血脂正常组与血脂紊乱组患儿中,高血压比例分别是12.5%(19/152)和20.1%(86/428),差异具有统计学意义(x2=4.362,P=0.037),比值比为1.760,95%可信区间为1.030～3.008.(2)血脂紊乱组的左、右颈总动脉IMT和颈总动脉平均IMT值均较血脂正常组偏高,但差异均无统计学意义(均P>0.05).血脂紊乱组的左、右颈内动脉IMT和颈内动脉平均IMT值分别是(0.66±0.15)mm、(0.65±0.15)mm和(0.65±0.15)mm,正常血脂组三者水平分别为(0.62±0.13)mm、(0.60±0.13)mm和(0.61±0.12)mm,组间差异均有统计学意义(均P<0.05).(3)双变量相关分析显示收缩压与年龄、BMI、BMI Z值、腰围、臀围、尿酸、丙氨酸转氨酶、甘油三酯、空腹胰岛素和稳态胰岛素抵抗指数呈正相关(均P<0.05);其中收缩压与臀围中度相关.颈总动脉和颈内动脉平均IMT也分别与年龄、BMI、腰围、臀围和TG呈正相关(均P<0.05).多元线性回归分析显示臀围和稳态模型胰岛素抵抗指数是收缩压的独立相关因素,腰围是颈总动脉和颈内动脉平均IMT的独立相关因素,甘油三酯还是颈内动脉平均IMT的独立相关因素.结论 (1)肥胖儿童青少年存在血脂代谢紊乱、高血压和动脉内膜增厚等血管病变,(2)脂代谢紊乱与血管病变密切相关,其中腰围和高甘油三酯血症是血管病变的高危因素.     

Psychological consequences of chronic physical illnesses in children and adolescents

Chronic illnesses in children and adolescents have devastating influence on them and their families. The patients have to cope up with illness, medication and it’s influence on their development. Consequently a large number of them have emotional disorders which influence the course and outcome of physical disorder. In recent few years, research has shifted its focus from merely figuring out the prevalence of the emotional disorders to understanding the adjustment to chronic illness under defined theoretical constructs. Apart from temperamental variation, family burden and functioning have been identified as factors operating in determining adjustment. Distress experienced by the family and disturbed family functioning directly influences the emotional outcome in physically disordered children. Comprehensive coordinated care services are required for integration of these patients into the community.     

Insulin resistance in obese children and adolescents

ObjectiveTo evaluate the presence of insulin resistance and its association with other metabolic abnormalities in obese children and adolescents.MethodsRetrospective study of 220 children and adolescents aged 5-14 years. Anthropometric measurements were performed (weight, height, and waist circumference) and clinical (gender, age, pubertal stage, and degree of obesity) and biochemical (glucose, insulin, total cholesterol, and fractions, triglycerides) data were analyzed. Insulin resistance was identified by the homeostasis model assessment for insulin resistance (HOMA-IR) index. The analysis of the differences between the variables of interest and the HOMA-IR quartiles was performed by ANOVA or Kruskal-Wallis tests.ResultsInsulin resistance was diagnosed in 33.20% of the sample. It was associated with low levels of high-density lipoprotein cholesterol (HDL-C; p = 0.044), waist circumference measurement (p = 0.030), and the set of clinical and metabolic (p = 0.000) alterations. Insulin-resistant individuals had higher mean age (p = 0.000), body mass index (BMI; p = 0.000), abdominal circumference (p = 0.000), median triglycerides (p = 0.001), total cholesterol (p ≤ 0.042), and low-density lipoprotein cholesterol (LDL–C; p ≤ 0.027); and lower HDL-C levels (p = 0.005). There was an increase in mean BMI (p = 0.000), abdominal circumference (p = 0.000), and median triglycerides (p = 0.002) as the values of HOMA -IR increased, with the exception of HDL-C, which decreased (p = 0.001). Those with the highest number of simultaneous alterations were between the second and third quartiles of the HOMA–IR index (p = 0.000).ConclusionThe results confirmed that insulin resistance is present in many obese children and adolescents, and that this condition is associated with alterations that represent an increased risk for developing metabolic disorders in adulthood.     

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目的了解不同葡萄糖耐量状态的肥胖儿童血清脂联素水平,探讨其与年龄、体重指数(BMI)、血脂、血糖及胰岛素水平的关系。方法选择2002～2004年于广州市儿童医院初诊并住院诊治的肥胖儿童52例,分为36例糖耐量正常(NGT)肥胖组和16例糖耐量受损(IGT)肥胖组。测定两组肥胖儿童和41例年龄、性别匹配的正常儿童空腹血清脂联素、胆固醇(CHO)、甘油三酯(TG)、低密度脂蛋白胆固醇(LDLC)、血糖和胰岛素(FINS),计算胰岛素抵抗指数(HOMAIR)。肥胖组儿童均做口服葡萄糖耐量试验(OGTT),测定OGTT2h血糖和胰岛素。结果正常对照组、NGT肥胖组及IGT肥胖组血清脂联素水平依次降低,HOMAIR依次升高,且均有统计学意义;相关性分析显示肥胖儿童血清脂联素与TG、LDLC、FINS呈显著负相关(P<0.05)。结论肥胖儿童血清脂联素水平降低,并与血脂、胰岛素抵抗密切相关;与NGT肥胖组相比,IGT肥胖组儿童的血清脂联素水平进一步降低。     

Aerobic fitness and visceral adipose tissue in children

AIM: To determine the relationship between aerobic fitness (peak VO2) and the volume of visceral adipose tissue (VAT) in children. METHODS: Participants were 30 males (13.7+/-0.5 y) and 22 females (13.5+/-0.5 y). Peak VO2 was determined using a continuous, incremental treadmill protocol to exhaustion. Abdominal VAT volume was measured by magnetic resonance imaging using multiple slices from vertebral levels L1-L5. Subcutaneous body fat measure was calculated as the sum of seven skinfolds (sigma7SKF). RESULTS: Females had significantly (p < or = 0.05) more VAT than males (1035+/-717.3 vs 678.6+/-361.5 cm3); however, male peak VO2 was higher (215+/-34 vs 182+/-20 ml/kg(0.61)/min). VAT was significantly (p < or = 0.05) negatively correlated with peak VO2 in both males (r = - 0.43) and females (r = - 0.45). Subcutaneous body fatness was significantly correlated with VAT in both males (r = 0.74) and females (r = 0.72), and was the single strongest determinant of VAT. CONCLUSION: Aerobic fitness is significantly inversely related to VAT, but subcutaneous body fatness is the single strongest determinant of VAT in children aged 13-14 y.     

The change in ghrelin and obestatin levels in obese children after weight reduction

Aim: To investigate the role of ghrelin and obestatin in obesity mechanisms.
Methods: A total of 88 obese children and 25 normal children were enrolled. Moreover, 46 obese children took part in a summer camp for weight reduction. Fasting ghrelin, obestatin and other biochemical parameters were measured in all subjects and re-measured in 45 obese children finishing the camp.
Results: The ghrelin levels in the control and obese groups were 67.26 ± 23.41 pmol/L and 56.53 ± 15.97 pmol/L with a significant difference (p = 0.039), while the obestatin levels (89.41 ± 23.63 vs. 83.13 ± 17.21 pmol/L) were not significantly different (p = 0.083). The ghrelin/obestatin ratio in the controls was significantly higher than that in the obese group (p = 0.014). In the latter, fasting insulin and alanine aminotransferase were independent factors for ghrelin; fasting insulin, weight and gender were independent factors for obestatin and alanine aminotransferase was an independent factor for ghrelin/obestatin. Moreover, ghrelin, obestatin and ghrelin/obestatin increased after weight reduction (p < 0.05, respectively), and the increment in ghrelin and obestatin was associated with a decrement in insulin resistance.
Conclusion: These data suggest that ghrelin, obestatin and/or the ghrelin/obestatin ratio are associated with obesity in childhood.