The objective of this technical report is to provide clinicians with actionable evidence-based information upon which to make treatment decisions. In addition, this report will provide an evidence base on which to inform clinical practice guidelines for the management and treatment of overweight and obesity in children and adolescents.

To this end, the goal of this report was to identify all relevant studies to answer 2 overarching key questions: (KQ1) “What are effective clinically based treatments for obesity?” and (KQ2) “What is the risk of comorbidities among children with obesity?” See Appendix 1 for the conceptual framework and a priori Key Questions.

Obesity is a common concern in pediatric practice. In caring for patients with obesity or patients who may be at risk for developing obesity, clinicians have many unanswered questions. Examples of these questions include: What is the best way to identify excess adiposity, and does the identification of obesity provide opportunities for treatment? If so, what evidence-based interventions for obesity treatment, delivered at least in part by clinicians in office-based settings, are most effective? Among children and adolescents identified as having obesity, does screening for comorbidities result in improved health outcomes?

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 US Preventive Services Task Force recommendation was that obesity treatment should include at least 26 hours of contact, including clinical care and other behavioral intervention (eg, guided physical activity). However, subsequent studies have failed to demonstrate a consistent hours-based dose-response. In addition, feasibility studies have clearly shown how unrealistic it is for primary care or tertiary care providers to deliver this many hours of treatment in real-world, clinical settings.2  Additional information is needed about resources or partnerships that help reach that contact hour goal, the essential components delivered during these contact hours, the period of time over which this care is delivered, and information about lower-intensity strategies with some effectiveness.

Of particular concern for primary care pediatricians is the need to understand how to approach recommendations for screening comorbidities in their patients with obesity. Although previous recommendations have supported screening for common comorbidities, such as dyslipidemia and diabetes, there has been conflicting evidence regarding timing and effectiveness of screening. Additional data are now available that provide clinicians and researchers with information about comorbidity prevalence and severity by obesity class. The intent is to help the clinician screen for comorbidities when there is a high likelihood of detecting an abnormality and when detection of that abnormality leads to treatment options that can improve child health. Obesity classifications, including a more granular categorization of obesity as classes I through III, might assist clinicians in determining for whom screening would be most useful rather than viewing screening as a homogeneous approach for anyone whose BMI is >95th percentile.

This review was designed to answer 2 overarching key questions: (KQ1) “What are effective clinic-based treatments for obesity?” and (KQ2) “What is the risk of comorbidities among children with obesity?” We developed this focus based on the needs of clinicians and the evidence required to inform the future development of clinical practice guidelines. This review will not attempt to quantify the magnitude of the effect of obesity on child or adult outcomes. It will also not attempt to address treatment strategies for comorbidities (eg, hypertension), as other guidelines and reviews are available to guide such treatment.

Rationale for KQ1 (Intervention Studies)

Clinicians are a regular source of trusted information for parents, including issues related to nutrition and activity, which are key components of obesity prevention and treatment. Clinicians need to know what strategies have high-quality evidence for effectiveness in preventing and treating obesity. Additionally, physicians need guidance on which treatments are effective for their patient population and how to use available resources. The full results of KQ1 are reported in an accompanying technical report.3 

Rationale for KQ2 (Comorbidity Studies)

Previous recommendations have included assessments of comorbidities, including hypertension, dyslipidemia, glucose, and others. It is not clear whether these assessments identify important health conditions or lead to improved treatment strategies. Additionally, it is not clear whether conducting these assessments would result in an adverse patient outcomes, such as further investigation for false-positive screening results. We will examine specific conditions previously recommended or that would reasonably require screening, as identified by the authors: dyslipidemia, hypertension, diabetes, liver function, depression, sleep apnea, and asthma. This is not intended to be a comprehensive list of all conditions comorbid with obesity but represents those most common and for which screening is potentially helpful.

We searched Pubmed and CENTRAL (for trials), completing the final search on April 6, 2018. An additional search was conducted to update the review, covering the time period April 7, 2018, through February 15, 2020. We combined the searches for both key questions because of significant overlap and to more efficiently review studies. Because our focus was on interventions that are relevant to primary care, we did not search other databases, such as ERIC or PsycInfo.

The complete search strategies are included in Appendix 2. Briefly, we searched for studies of children or adolescents, with a focus on overweight, obesity, or weight status; involving clinicians, health care, or other treatment or screening (KQ1); and examining common comorbidities (KQ2). For both questions, we limited only using key words, not filters, to ensure we included the newest studies that were not yet fully indexed. No date limits were placed on searches. In practice, this meant we reviewed studies from 1950 to 2020, although <2% were published before 1980.

The complete inclusion criteria are included in Appendix 3.

Inclusion Criteria Common to All Studies

All studies were required to include children ages 2 to 18 years, although studies could also include young adults up to age 25 if stratified from older adult participants, as long as children under 18 were also included. Children could have other conditions (eg, asthma) as long as they were not known to cause obesity, such as Prader-Willi syndrome, obesogenic medication (eg, antipsychotics), or known genetic mutations (eg, MC4R) associated with obesity. All studies had to originate from the Organization for Economic Cooperation and Development member countries and had to be available in English.

Inclusion Criteria for KQ2 (Comorbidity Studies)

We included studies with a primary aim of comparing comorbidities among those with and without obesity or by severity of obesity. Obesity and the comorbidity had to be measured contemporaneously to reflect the practice of clinical screening. Obesity had to be categorized using a BMI-based measure into accepted categories (ie, healthy weight, overweight, class I obesity, class II obesity, class III obesity).

These categories could be based on percentiles or z-scores and could use the distributions relevant to the studied population (eg, World Health Organization [WHO] or the US Centers for Disease Control and Prevention [CDC]). Comorbidities had to include 1 or more of: lipids, blood pressure, liver function, glucose metabolism, obstructive sleep apnea, asthma, or depression.

See the other technical report for a detailed description of KQ1 inclusion criteria.3 

We used Covidence (Melbourne, Australia) to manage the review process. Covidence is a program for online collaboration and management of systematic reviews. All abstracts were reviewed by 2 independent reviewers for inclusion in full-text review. Articles were reviewed by 2 reviewers, with conflicts discussed and resolved. Articles excluded at this stage were assigned an exclusion reason, with a hierarchy as shown in Appendix 4.

Data Extraction and Quality Assessment

All articles deemed relevant for full text inclusion were categorized into different data extraction strategies. We did not include a specific quality assessment for the comorbidity studies.

KQ2 (Comorbidity Studies) Extraction

All studies were extracted by 2 reviewers. Extraction of these studies included reporting prevalence of comorbidities or mean values of laboratory parameters by weight classification. We included healthy weight, overweight, class I obesity, class II obesity, and class III obesity. However, because all classes of obesity severity are not always reported, these classes may include higher groups. For example, reporting of ≥95th percentile would only be considered class I obesity, although children at higher levels may be included. (See other technical report for detailed description of KQ1 extraction procedures.)

Data Synthesis and Analysis

Our primary method of data synthesis is narrative. To allow broad inclusion, we did not limit to specific designs or measures that would facilitate meta-analysis. We report on studies in each group, based on their type and design, and we report findings for outcomes other than BMI.

A total of 15 988 studies were screened in the title and abstract stage. Of these, 1642 were given a full-text review. Excluded studies (n = 1260) were most commonly not original research, did not compare comorbidities by obesity (KQ2), or were not health-care system based (KQ1). See Fig 1 for the complete PRISMA diagram. Of the 382 studies included, 215 were intervention studies and 167 were comorbidity studies. This paper focuses on the 167 comorbidity studies.

FIGURE 1

PRISMA Diagram.

HDL Cholesterol

A total of 39 studies examined the prevalence of abnormal high-density lipoprotein (HDL),442  whereas 49 provided mean values for HDL.58,10,13,18,22,24,32,33,35,36,4074 Table 1 reports the prevalence of abnormal HDL. Different countries report significantly different prevalence of abnormal HDL, with Korea having the highest prevalence18,30  and Japan the lowest.42  The majority of the 39 reported studies reporting the prevalence of abnormal HDL were conducted in the United States (24 of 39). Abnormal HDL was defined variably as <35 mg/dL, <40 mg/dL, and <50 mg/dL or <1.0 mmol/L. The most consistent findings were seen when using the definition of <40 mg/dL and when larger sample sizes were included. There was consistency of an inverse dose-response relationship, with increasing weight category associated with lower HDL. Few studies provided detailed information by obesity class, so less could be concluded when examining the prevalence of abnormal HDL within samples of increasing severity of obesity status. In general, overall prevalence of abnormal HDL increases from about 10% to 40% when children’s weight category was healthy weight versus obesity. The prevalence varied by age, with younger ages associated with lower prevalence of abnormal HDL. For example, in a study of 9- to 13-year-olds, those who had healthy weight had a prevalence of abnormal HDL of 10.2%, whereas those with obesity had a prevalence of abnormal HDL of 32.5%.15  In a study of 14- to 18-year-olds, those who had healthy weight had a prevalence of abnormal HDL of 13.2% and those with obesity had a prevalence of abnormal HDL of 38.9%.40  When studies report larger age ranges, it is difficult to see these distinctions, and the mean prevalence might be obfuscating the differences in prevalence at the younger versus older ages. A few studies stratified their findings by biological sex. In 2 US-based studies, there appears to be a higher prevalence of abnormal HDL in female children of both healthy weight and overweight, but the prevalence is similar regardless of sex once children are categorized as obese.12,20  Studies conducted in other countries also report differences by biological sex, but not always in the same direction or to the same degree.9,19,35,42  Caution should be used in interpreting these results when small sample sizes were used.

TABLE 1

Prevalence of Abnormal HDL (n = 39)

First AuthorCountryAges (y)NDefinition of AbnormalSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPWeight DefinitionsPopulation 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; <50 mg/dL females   83% 90.8%    <.000   
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, <40 mg/dL males   30 56 57   <.005   
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      .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 
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, 2: BMI 50–60, 3: BMI >60 Bariatric surgery patients 
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 KNHANES  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    
Serap Turkey 6–16 284 NCEP values Males  3.8  28.1   <.001   
     Females  6.5  44.3   <.001  Pediatric endocrinology patients 
Pan USA 12–19 4450 <35 mg/dL  8.5% 5.6 12.7 25.6   <.05 both  NHANES 1999–2002 
Messiah USA 8–14 1698 <40 mg/dL 8–11 y  11.04 31.81 36.21      
First AuthorCountryAges (y)NDefinition of AbnormalSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPWeight DefinitionsPopulation 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; <50 mg/dL females   83% 90.8%    <.000   
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, <40 mg/dL males   30 56 57   <.005   
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      .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 
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, 2: BMI 50–60, 3: BMI >60 Bariatric surgery patients 
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 KNHANES  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    
Serap Turkey 6–16 284 NCEP values Males  3.8  28.1   <.001   
     Females  6.5  44.3   <.001  Pediatric endocrinology patients 
Pan USA 12–19 4450 <35 mg/dL  8.5% 5.6 12.7 25.6   <.05 both  NHANES 1999–2002 
Messiah USA 8–14 1698 <40 mg/dL 8–11 y  11.04 31.81 36.21      

NR, not reported; NS, not significant;  NHANES, National Health and Nutrition Examination Survey; KNHANES, Korean National Health and Nutrition Examination Survey.

Table 2 reports the mean HDL values. Mean HDL values corroborate the findings regarding the prevalence of abnormal HDL, highlighting that age, sex, and country affect the findings of mean HDL values. Also apparent is the importance of sample size to lead to a stable mean value. Several of these studies reported mean values for large age ranges. In almost all of these studies, mean HDL decreases as weight category increases, validating the association between the 2.

TABLE 2

Mean HDL (n = 49)

First AuthorCountryAges (y)NUnitsSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIP valueNotesWeight DefinitionsPopulation 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 (160 for lipids) mg/dL   52 43 43   <.005   Rural Georgia 
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 = 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 
Simsek Turkey Mean 10.8 115 mg/dL   52.5  47   <.001    
Salawi Canada 6–19 345 mmol/L    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 
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    
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    
     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, SO 120%/95th Obesity clinic patients 
     Females    45 45  .01  OB 95th, SO 120%/95th Obesity clinic patients 
Hadjiyannakis Canada 5–17 847 mmol/L  1.12   1.15 1.11 1.08 NR   Pediatric weight management program patients 
Higgins Canada 5–19 1332 mmol/L Males  1.26 1.18 1.07   <.05  OW = 85th–97th %ile, OB > 97 Community 
    See males Females  1.30 1.27 1.15   NS  OW = 85th–97th %ile, OB > 97 Community 
Kim Korea 12–13 120 mg/dL   58.9 54.4    .047   School based 
Kloppenberg Denmark Median 12 3978 mmol/L Males  1.5 1.3 1.14   <.001 P value includes differences by sex HW: <90th, OW: 90th–99th, OB: >99th Weight management clinic + population-based 
     Females  1.5 1.3 1.14   <.001 P value includes differences by sex HW: <90th, OW: 90th–99th, OB: >99th Weight management clinic + population-based 
Seth USA Mean 13 767 mg/dL    44 38 38 38.5 .072   Steatohepatitis clinic patients 
Sougawa Japan 12–18 1679 mg/dL Males 64.0 65.2 58.3    <.001   Schools 
    mg/dL Females 68.4 68.5 67.7    .709   Schools 
First AuthorCountryAges (y)NUnitsSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIP valueNotesWeight DefinitionsPopulation 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 (160 for lipids) mg/dL   52 43 43   <.005   Rural Georgia 
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 = 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 
Simsek Turkey Mean 10.8 115 mg/dL   52.5  47   <.001    
Salawi Canada 6–19 345 mmol/L    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 
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    
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    
     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, SO 120%/95th Obesity clinic patients 
     Females    45 45  .01  OB 95th, SO 120%/95th Obesity clinic patients 
Hadjiyannakis Canada 5–17 847 mmol/L  1.12   1.15 1.11 1.08 NR   Pediatric weight management program patients 
Higgins Canada 5–19 1332 mmol/L Males  1.26 1.18 1.07   <.05  OW = 85th–97th %ile, OB > 97 Community 
    See males Females  1.30 1.27 1.15   NS  OW = 85th–97th %ile, OB > 97 Community 
Kim Korea 12–13 120 mg/dL   58.9 54.4    .047   School based 
Kloppenberg Denmark Median 12 3978 mmol/L Males  1.5 1.3 1.14   <.001 P value includes differences by sex HW: <90th, OW: 90th–99th, OB: >99th Weight management clinic + population-based 
     Females  1.5 1.3 1.14   <.001 P value includes differences by sex HW: <90th, OW: 90th–99th, OB: >99th Weight management clinic + population-based 
Seth USA Mean 13 767 mg/dL    44 38 38 38.5 .072   Steatohepatitis clinic patients 
Sougawa Japan 12–18 1679 mg/dL Males 64.0 65.2 58.3    <.001   Schools 
    mg/dL Females 68.4 68.5 67.7    .709   Schools 

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.

LDL Cholesterol

A total of 26 studies examined the prevalence of abnormal low-density lipoprotein (LDL),410,12,13,15,16, 18,19,2124,26,28,31,3438,41  whereas 41 provided mean values for LDL.58, 10,13,18,22,24,33,35,36,40,41,4346,5052, 5467,69,70,7275 Table 3 reports the prevalence of abnormal LDL. Approximately half (n = 13) of the studies evaluated children 9 years or older, a time point associated with physiologic increases in LDL cholesterol.76  The remaining studies included children as young as 3 and up to 19 years of age. Sample size varied from 101 to 29 286; 13 of 23 studies reported sample sizes of 1000 or greater. One challenge in interpreting these data are the variation in definition of and reported units for abnormal LDL. Authors defined abnormal LDL as >110 mg/dL or >2.6 mmol/L through >130 mg/dL or >3.4 mmol/L. In 1 instance, authors used >75th percentile of National Cholesterol Education Program (NCEP) standards.24  In nearly all the studies, abnormal LDL was more prevalent in children with increasing BMI, and when comparing healthy weight with obesity, this difference consistently achieved statistical significance. The majority of studies did not include a significant number of children in each obesity classification; therefore, it is difficult to conclude whether abnormal LDL is more common by obesity classification. Among the 3 studies that reported male and female LDL separately, there was not a significant difference at any weight classification.5,9,12,19,35  Similarly to the LDL prevalence studies, the most evidence for mean LDL in populations includes children of school age and older (Table 4). Only 1 of the identified studies exclusively included children younger than 5 years46 ; therefore, it is difficult to draw conclusions in this younger age group. Sample size of the reported studies ranged from 41 to 2244. Several, but not all, studies reported male and female LDL levels separately. Mean LDL was reported in some cases in mg/dL and in other cases as mmol/L. Across all studies, mean LDL tended to increase with increasing BMI; however, only the difference between healthy weight and obese consistently achieved statistical significance. In 1 Korean study that evaluated mean LDL in 1998 and again in 2001, secular increases in mean LDL were also observed.17  Although in some cases, females have higher mean LDL than males at matched age and BMI, this difference was inconsistent and did not achieve statistical significance. However, the difference between mean LDL when comparing healthy weight and obesity was more pronounced in males than females. It is interesting to note that in all studies, even in the highest BMI subcategories, mean LDL values did not exceed commonly accepted definitions for normal.

TABLE 3

Prevalence of Abnormal LDL (n = 26)

First AuthorCountryAges (y)NDefinition of AbnormalSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPWeight DefinitionsPopulation 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 (160 for lipids) >110 mg/dL   19 25 19   NS   
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    10.7   .049   
Salvatore USA 3–18 101 >110 mg/dL     55.6 44.4 23.3 .041 Class 1: >100% to 120%; class II/III: standard Pediatric gastroenterology 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: BMI 50–60, 3: BMI >60 Bariatric surgery patients 
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   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 120%/95th Obesity clinic patients 
     Females       NS OB 95th, SO 120%/95th Obesity clinic patients 
Gunes USA 11–18 363 >130 mg/dL Males   96.5 86.4   .135  Adolescent clinic patients 
     Females   86.4 89   .612  Adolescent clinic patients 
Hadjiyannakis Canada 5–17 847 >3.4 mmol/L  10   11 11 NR  Pediatric weight management program patients 
First AuthorCountryAges (y)NDefinition of AbnormalSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPWeight DefinitionsPopulation 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 (160 for lipids) >110 mg/dL   19 25 19   NS   
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    10.7   .049   
Salvatore USA 3–18 101 >110 mg/dL     55.6 44.4 23.3 .041 Class 1: >100% to 120%; class II/III: standard Pediatric gastroenterology 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: BMI 50–60, 3: BMI >60 Bariatric surgery patients 
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   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 120%/95th Obesity clinic patients 
     Females       NS OB 95th, SO 120%/95th Obesity clinic patients 
Gunes USA 11–18 363 >130 mg/dL Males   96.5 86.4   .135  Adolescent clinic patients 
     Females   86.4 89   .612  Adolescent clinic patients 
Hadjiyannakis Canada 5–17 847 >3.4 mmol/L  10   11 11 NR  Pediatric weight management program patients 

NR, not reported; NS, not significant; OB, obese; SO, severe obesity.

TABLE 4

Mean LDL (n = 41)

First AuthorCountryAges (y)NUnitsSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation 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 (160 for lipids) mg/dL   87 91 93   NS   Rural Georgia 
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 = 90 Includes class IV  
Valentini Italy 5–18 84 mg/dL   96.25 110.77    .013   Patients with Down syndrome 
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 
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 (Puerto Rico) 12–16 352 mg/dL  73.5 65.0 75.5    .3367    
Maximova Canada 6–19 2087 mmol/L 6–11 y  2.2 2.6    NR    
     12–19 y  2.2 2.5    NR    
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 
Avnieli Velfer Israel 2–18 1027 mg/dL Males    100 100  .26  OB 95th, SO 120%/95th Obesity clinic patients 
    mg/dL Females    96 102  .18  OB 95th, SO 120%/95th Obesity clinic 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 differences by sex HW: <90th, OW: 90th–99th, OB: >99th Weight management clinic + population-based 
     Females  2.0 2.2 2.3   <.001 P value includes differences by sex HW: <90th, OW: 90th–99th, OB: >99th Weight management clinic + population-based 
Seth USA Mean 13 767 mg/dL    151 195.5 207 178 .78   Steatohepatitis clinic patients 
First AuthorCountryAges (y)NUnitsSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation 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 (160 for lipids) mg/dL   87 91 93   NS   Rural Georgia 
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 = 90 Includes class IV  
Valentini Italy 5–18 84 mg/dL   96.25 110.77    .013   Patients with Down syndrome 
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 
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 (Puerto Rico) 12–16 352 mg/dL  73.5 65.0 75.5    .3367    
Maximova Canada 6–19 2087 mmol/L 6–11 y  2.2 2.6    NR    
     12–19 y  2.2 2.5    NR    
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 
Avnieli Velfer Israel 2–18 1027 mg/dL Males    100 100  .26  OB 95th, SO 120%/95th Obesity clinic patients 
    mg/dL Females    96 102  .18  OB 95th, SO 120%/95th Obesity clinic 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 differences by sex HW: <90th, OW: 90th–99th, OB: >99th Weight management clinic + population-based 
     Females  2.0 2.2 2.3   <.001 P value includes differences by sex HW: <90th, OW: 90th–99th, OB: >99th Weight management clinic + 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.

Triglycerides

A total of 38 studies examined the prevalence of abnormal triglycerides (TG),426,2832,3442  whereas 48 provided mean values for TG.58,10,13,18,22,24,32,35,36,4060,6275,77 Table 5 reports the prevalence of abnormal TG. About half of the 38 reported studies were conducted in the United States (20 of 38). Country comparisons are not possible given the variety of cutoff values employed. However, there is consistency of a dose-response relationship with increasing weight category associated with higher TG prevalence in most settings studied. Few studies provide detailed information broken down by obesity class, so less can be concluded when examining the prevalence of abnormal TG and increasing severity of obesity status. When studies report larger age ranges, it is difficult to see these distinctions, and the mean prevalence might be masking any potential differences in prevalence at the younger versus older ages. A few studies stratified their findings by gender, but the pattern of high TG prevalence was not always in the same direction or to the same degree. Caution should be used in interpreting these results when small sample sizes were used.

TABLE 5

Prevalence of Abnormal Triglycerides (n = 38)

First AuthorCountryAges (y)NDefinition of AbnormalSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPWeight definitionsPopulation 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 (160 for lipids) >150 mg/dL   11 18   NS  Rural Georgia 
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 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 120%; class II/III: standard Pediatric gastroenterology patients 
Perez USA (Puerto Rico) 12–18 101 ≥100 mg/dL   18.9 41.7    .012   
O’Hara USA 3–19 382 >75 mg/dL 0–9 y; >90 mg/dL 10–19 y  72  63 55 74 76 NS  Rural pediatric weight management program patients 
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 50–60, 3: BMI >60 Bariatric surgery patients 
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   
Marcus USA Mean 11.8 6358 >110 mg/dL   11.5 25.4 40.7  44.3 <.001   
Kim Korea 10–18 1412 >130 mg/dL 1998 KNHANES  10.4 23.1 38.2   <.05   
   1158  2001 KNHANES  15.6 29.8 35.1   <.05   
Botton France 8–17 452 >1.5 mmol/L   3.7 10   0.08    
Serap Turkey 6–16 284 NCEP values Males  1.9  27   <.001  Pediatric endocrinology patients 
     Females  8.6  24.7   <.001   
Del- Rio-Navarro Mexico 6–13 1819 >150 mg/dL Males  7.2 12.0 18.5   <.05 OB   
     Females  9.6 22.6 22.2   <.05   
Pan USA 12–19 4450 >110 mg/dL No 22.20% 19.2 24.7 48.9   <.05 OB  NHANES 1999–2002 
Messiah USA 8–14 1698 >110 mg/dL No  12–14: 17.50 12–14: 15.47 12-14: 52.40      
Lambert Canada 9–16 3613 >1.7 mmol/L Males  1.0 11.7 17.5   <.0001   
     Females  3.7 10.4 11.8   .002   
Valery Australia 5–17 158 NR No  20    .134  Indigenous youth 
Avnieli Velfer Israel 2–18 1027 >95th percentile Males    45 58.5  .001 OB 95th, SO 120%/95th Obesity clinic patients 
     Females       NS OB 95th, SO 120%/95th Obesity clinic patients 
Gunes USA 11–18 363 >130 mg/dL Males   58.6 70.4   .223  Adolescent clinic patients 
     Females   72.4 79.8   .247  Adolescent clinic patients 
Hadjiyannakis Canada 5–17 847 >1.5 mmol/L  36   30 40 39 NR  Pediatric weight management program patients 
Stolzman USA 12–17 62 >125 mg/dL   10    NS  Community recruitment 
First AuthorCountryAges (y)NDefinition of AbnormalSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPWeight definitionsPopulation 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 (160 for lipids) >150 mg/dL   11 18   NS  Rural Georgia 
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 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 120%; class II/III: standard Pediatric gastroenterology patients 
Perez USA (Puerto Rico) 12–18 101 ≥100 mg/dL   18.9 41.7    .012   
O’Hara USA 3–19 382 >75 mg/dL 0–9 y; >90 mg/dL 10–19 y  72  63 55 74 76 NS  Rural pediatric weight management program patients 
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 50–60, 3: BMI >60 Bariatric surgery patients 
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   
Marcus USA Mean 11.8 6358 >110 mg/dL   11.5 25.4 40.7  44.3 <.001   
Kim Korea 10–18 1412 >130 mg/dL 1998 KNHANES  10.4 23.1 38.2   <.05   
   1158  2001 KNHANES  15.6 29.8 35.1   <.05   
Botton France 8–17 452 >1.5 mmol/L   3.7 10   0.08    
Serap Turkey 6–16 284 NCEP values Males  1.9  27   <.001  Pediatric endocrinology patients 
     Females  8.6  24.7   <.001   
Del- Rio-Navarro Mexico 6–13 1819 >150 mg/dL Males  7.2 12.0 18.5   <.05 OB   
     Females  9.6 22.6 22.2   <.05   
Pan USA 12–19 4450 >110 mg/dL No 22.20% 19.2 24.7 48.9   <.05 OB  NHANES 1999–2002 
Messiah USA 8–14 1698 >110 mg/dL No  12–14: 17.50 12–14: 15.47 12-14: 52.40      
Lambert Canada 9–16 3613 >1.7 mmol/L Males  1.0 11.7 17.5   <.0001   
     Females  3.7 10.4 11.8   .002   
Valery Australia 5–17 158 NR No  20    .134  Indigenous youth 
Avnieli Velfer Israel 2–18 1027 >95th percentile Males    45 58.5  .001 OB 95th, SO 120%/95th Obesity clinic patients 
     Females       NS OB 95th, SO 120%/95th Obesity clinic patients 
Gunes USA 11–18 363 >130 mg/dL Males   58.6 70.4   .223  Adolescent clinic patients 
     Females   72.4 79.8   .247  Adolescent clinic patients 
Hadjiyannakis Canada 5–17 847 >1.5 mmol/L  36   30 40 39 NR  Pediatric weight management program patients 
Stolzman USA 12–17 62 >125 mg/dL   10    NS  Community recruitment 

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

Table 6 reports the mean TG values. The sample sizes of the studies presented vary from 41 to 3978. In almost all of these studies, mean TG value increases as weight category increases, validating the association between the 2. In the majority of studies, the mean TG value is <130 mg/dL.

TABLE 6

Mean Triglycerides (n = 48)

First AuthorCountryAges (y)NUnitsSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight definitionsPopulation 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 (160 for lipids) mg/dL   88 89 111   NS   Rural Georgia 
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 = 102 Includes class IV  
Valerio Italy 3–16 150 mg/dL Children  59.7  80.6   .005    
     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 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 (Puerto Rico) 12–18 101 mg/dL   83.0 94.0    .022    
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 (Puerto Rico) 12–16 352 mg/dL  58.0 57.0 58.0    .6971    
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    
     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 = 0.80 Median = 0.90    .070   Indigenous youth 
Avnieli Velfer Israel 2–18 1027 mg/dL Males    120 120  .93  OB 95th, SO 120%/95th Obesity clinic patients 
     Females    126 126  .01  OB 95th, SO 120%/95th Obesity clinic 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 = 85th–97th %ile, OB >97 Community 
     Females  1.23 0.45 1.56   <.05  OW = 85th–97th %ile, OB > 97 Community 
Kim Korea 12–13 120 mg/dL   68.5 94.0    .008   School based 
Kloppenberg Denmark Median 12 3978 mmol/L Males  0.5 2.2 0.89   <.001 P value includes differences by sex HW: <90th, OW: 90th–99th, OB: >99th Weight management clinic + population-based 
     Females  0.6 0.8 1.01   <.001 P value includes differences by sex HW: <90th, OW: 90th–99th, OB: >99th Weight management clinic + population-based 
Seth USA Mean 13 767 mg/dL    102 133 135 127 .072   Steatohepatitis clinic patients 
Sougawa Japan 12–18 1679 mg/dL Males 60.0 55.3 81.4    <.001   Schools 
     Females 59.1 58.8 62.5    .236   Schools 
First AuthorCountryAges (y)NUnitsSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight definitionsPopulation 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 (160 for lipids) mg/dL   88 89 111   NS   Rural Georgia 
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 = 102 Includes class IV  
Valerio Italy 3–16 150 mg/dL Children  59.7  80.6   .005    
     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 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 (Puerto Rico) 12–18 101 mg/dL   83.0 94.0    .022    
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 (Puerto Rico) 12–16 352 mg/dL  58.0 57.0 58.0    .6971    
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    
     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 = 0.80 Median = 0.90    .070   Indigenous youth 
Avnieli Velfer Israel 2–18 1027 mg/dL Males    120 120  .93  OB 95th, SO 120%/95th Obesity clinic patients 
     Females    126 126  .01  OB 95th, SO 120%/95th Obesity clinic 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 = 85th–97th %ile, OB >97 Community 
     Females  1.23 0.45 1.56   <.05  OW = 85th–97th %ile, OB > 97 Community 
Kim Korea 12–13 120 mg/dL   68.5 94.0    .008   School based 
Kloppenberg Denmark Median 12 3978 mmol/L Males  0.5 2.2 0.89   <.001 P value includes differences by sex HW: <90th, OW: 90th–99th, OB: >99th Weight management clinic + population-based 
     Females  0.6 0.8 1.01   <.001 P value includes differences by sex HW: <90th, OW: 90th–99th, OB: >99th Weight management clinic + population-based 
Seth USA Mean 13 767 mg/dL    102 133 135 127 .072   Steatohepatitis clinic patients 
Sougawa Japan 12–18 1679 mg/dL Males 60.0 55.3 81.4    <.001   Schools 
     Females 59.1 58.8 62.5    .236   Schools 

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

Total Cholesterol

A total of 23 studies examined the prevalence of abnormal total cholesterol,610,12,13,15,16,18,19,2124, 27,28,3438,78  whereas 42 provided mean values for total cholesterol.58,10,13,18,22, 24,32,33,35,36,4347,4955,5759, 6166,6975,79  In large (>20 000) population based studies, the prevalence of abnormal cholesterol (>200 mg/dL) in children of normal weight ranged from 7.5% to 8.3%, in children with overweight ranged from 10.0% to 12.7%, and in children with obesity ranged from 14.5% to 16.9% (Table 7).15,16,21  There was a significant difference in prevalence of elevated cholesterol between children of normal weight and children with overweight and obesity. In 6 medium-sized studies of children (n = 2000–9000), 2 studies did not provide statistical testing. In the remaining 4 studies, 2 studies used >200 mg/dL as a cutoff for abnormal cholesterol, and 2 studies used >170 mg/dL and >4.4 mmol/L. One study showed a significant difference in the prevalence of elevated cholesterol among children of normal weight and children with obesity; a second 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 weight was 16.9% to 31%, for children who were overweight was 10.0% to 34.5%, and for children with obesity was 14.3% to 35.5%. There were 16 studies of children including 100 to 1412 children. Three studies did not provide statistical testing. Of the remaining 13 studies, 6 used 200 mg/dL as a cutoff for abnormal values, 4 used 170 mg/dL, and 2 used NCEP guidelines. Five studies did not include children with healthy weight. In the 7 studies remaining, 4 showed significant differences in total cholesterol between children with healthy weight and children with obesity.

TABLE 7

Prevalence of Abnormal Total Cholesterol (n = 23)

First AuthorCountryAges (y)NDefinition of AbnormalSubgroupTotalHealthyOverweightClass IClass IIClass IIIPWeight DefinitionsPopulation 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 grade) 29286 >200 mg/dL   8.3 12.7 16.9   <.01  Appalachian population school-aged children 
Davis USA 7–18 211 (160 for lipids) >170 mg/dL   23 21 34   NR  Rural Georgia 
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    24   <.001   
Salvatore USA 3–18 101 >170 mg/dL    66.7 67.9 48.1 29.0 .012 Class 1: >100% to 120% Pediatric 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 reported separately 
   1158  2001 KNHANES  7.3 14.4 18.6   <.05  2001 KHNANES 
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 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 
First AuthorCountryAges (y)NDefinition of AbnormalSubgroupTotalHealthyOverweightClass IClass IIClass IIIPWeight DefinitionsPopulation 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 grade) 29286 >200 mg/dL   8.3 12.7 16.9   <.01  Appalachian population school-aged children 
Davis USA 7–18 211 (160 for lipids) >170 mg/dL   23 21 34   NR  Rural Georgia 
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    24   <.001   
Salvatore USA 3–18 101 >170 mg/dL    66.7 67.9 48.1 29.0 .012 Class 1: >100% to 120% Pediatric 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 reported separately 
   1158  2001 KNHANES  7.3 14.4 18.6   <.05  2001 KHNANES 
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 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.

Of the 42 studies reporting mean cholesterol levels, 3 studies did not report statistical testing (Table 8). Of the remaining 39 studies, 13 reported significant differences between mean cholesterol levels in children with healthy weight and children with obesity. One study reported significant differences in males but not females, 1 study reported significant differences in females but not males, and a third reported differences in both sexes.

TABLE 8

Mean Total Cholesterol (n = 42)

First AuthorCountryAges (y)NUnitsSubgroupTotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation Info
Friedland Israel 6–17 142 mg/dL   143.3 164.1 177.6   <.05    
Davis USA 7–18 211 (160 for lipids) mg/dL   155 153 159   NS   Rural Georgia 
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 = 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    
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    
     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 versus HW   Children of 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    
Botton France 8–17 452 mmol/L Males 4.05 4.04 4.14    NS    
     Females 4.30 4.29 4.32    NS    
Serap Turkey 6–16 284 mg/dL Males  129.8  161.3   <0.05   Pediatric endocrinology patients 
     Females  132.1  162.1   <.05    
Craig UK 4–18 1944 mmol/L 4–10 y males  4.18 4.29    .477    
     4–10 y females  4.33 4.36    .826    
     11–18 y males  3.94 3.89    .945    
     11–18 y females  4.15 4.06    .458    
Avnieli Velfer Israel 2–18 1027 mg/dL Males    168 156  .16  OB 95th, SO 120%/95th Obesity clinic patients 
     Females    156 156  .8  OB 95th, SO 120%/95th Obesity clinic patients 
Hadjiyannakis Canada 5–17 847 mmol/L  4.20   4.20 4.20 4.14 NR   Pediatric weight management program patients 
Higgins Canada 5–19 1332 mmol/L Males  3.66 3.55 3.76   NS  OW = 85th–97th %ile, OB >97th Community 
     Females  3.83 4.03 3.78   NS  OW = 85th–97th %ile, OB >97th Community 
Kim Korea 12–13 120 mg/dL   156.5 170.0    .014   School based 
Kloppenberg Denmark Median 12 3978 mmol/L Males  3.7 3.9 3.94   <.001 P value includes differences by sex HW: <90th, OW: 90th–99th, OB: >99th Weight management clinic + population-based 
     Females  3.9 3.9 3.94   <.001 P value includes differences by sex HW: <90th, OW: 90th–99th, OB: >99th Weight management clinic + population-based 
First AuthorCountryAges (y)NUnitsSubgroupTotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation Info
Friedland Israel 6–17 142 mg/dL   143.3 164.1 177.6   <.05    
Davis USA 7–18 211 (160 for lipids) mg/dL   155 153 159   NS   Rural Georgia 
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 = 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    
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    
     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 versus HW   Children of 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    
Botton France 8–17 452 mmol/L Males 4.05 4.04 4.14    NS    
     Females 4.30 4.29 4.32    NS    
Serap Turkey 6–16 284 mg/dL Males  129.8  161.3   <0.05   Pediatric endocrinology patients 
     Females  132.1  162.1   <.05    
Craig UK 4–18 1944 mmol/L 4–10 y males  4.18 4.29    .477    
     4–10 y females  4.33 4.36    .826    
     11–18 y males  3.94 3.89    .945    
     11–18 y females  4.15 4.06    .458    
Avnieli Velfer Israel 2–18 1027 mg/dL Males    168 156  .16  OB 95th, SO 120%/95th Obesity clinic patients 
     Females    156 156  .8  OB 95th, SO 120%/95th Obesity clinic patients 
Hadjiyannakis Canada 5–17 847 mmol/L  4.20   4.20 4.20 4.14 NR   Pediatric weight management program patients 
Higgins Canada 5–19 1332 mmol/L Males  3.66 3.55 3.76   NS  OW = 85th–97th %ile, OB >97th Community 
     Females  3.83 4.03 3.78   NS  OW = 85th–97th %ile, OB >97th Community 
Kim Korea 12–13 120 mg/dL   156.5 170.0    .014   School based 
Kloppenberg Denmark Median 12 3978 mmol/L Males  3.7 3.9 3.94   <.001 P value includes differences by sex HW: <90th, OW: 90th–99th, OB: >99th Weight management clinic + population-based 
     Females  3.9 3.9 3.94   <.001 P value includes differences by sex HW: <90th, OW: 90th–99th, OB: >99th Weight management clinic + population-based 

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

Dyslipidemia

An additional 6 studies examined the prevalence of dyslipidemia.13,26,8083 Table 9 reports the prevalence of dyslipidemia (n = 6). The likely reason for the low number of studies in this category is the high variance in how dyslipidemia is defined. In 2 of these studies, similar criteria were listed: low HDL, high LDL, and high TG. In 1 study, a total cholesterol >200 mg/dL was also required for the diagnosis of dyslipidemia. In another study, being on a cholesterol-lowering medication also allowed patients to meet criteria. A third study relied on physician diagnosis of dyslipidemia only. The sample sizes for 2 of these studies were more than 10 000 participants. In general, the prevalence of dyslipidemia increased when comparing healthy weight with overweight and overweight with obesity. When comparing healthy weight with obesity, the prevalence (or odds ratio) nearly doubled. Caution should be used when interpreting these results given the inconsistent definition of dyslipidemia.

TABLE 9

Prevalence of Dyslipidemia (n = 6)

First AuthorCountryAges (y)NSubgroup (eg, M/F)Definition of AbnormalTotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation Info
Michalsky USA 13–19 242  High LDL or TG, low HDL, or medication 50.4   52.2 53.2 41.7 NS N = 238 1: BMI 30–50, 2: BMI 50–60, 3: BMI >60 Bariatric surgery patients 
Redonco USA 2–17.9 11348  Physician diagnosed 3.8% OR = 1.0 OR = 1.4 OR = 2.2   <.05   Patients with type 1 diabetes mellitus 
Jayawardene USA 12–19 23438 Males HDL < 40, LDL > 130, TG > 130, or TC > 200  22.7 38.0 53.7 68.7     NHANES 1999–2014 
    Females   20.0 26.3 32.5 40.2      
Tsao-Wu US 2–5 154  Guided by 2011 NHLBI statement    27.6 17.0 30.8 NR   Weight management clinic patients 
         37.2 36.3 36.1 NR   Weight management clinic patients 
         34.8 38.4 35.2 NR   Weight management clinic patients 
Lennerz Germany 14–24 431  Any abnormal lipid    28 24 37 .02   Weight management program patients + some community 
Hadjiyannakis Canada 5–17 847  Any lipid abnormality 20   17 23 21 NR   Pediatric weight management program patients 
First AuthorCountryAges (y)NSubgroup (eg, M/F)Definition of AbnormalTotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation Info
Michalsky USA 13–19 242  High LDL or TG, low HDL, or medication 50.4   52.2 53.2 41.7 NS N = 238 1: BMI 30–50, 2: BMI 50–60, 3: BMI >60 Bariatric surgery patients 
Redonco USA 2–17.9 11348  Physician diagnosed 3.8% OR = 1.0 OR = 1.4 OR = 2.2   <.05   Patients with type 1 diabetes mellitus 
Jayawardene USA 12–19 23438 Males HDL < 40, LDL > 130, TG > 130, or TC > 200  22.7 38.0 53.7 68.7     NHANES 1999–2014 
    Females   20.0 26.3 32.5 40.2      
Tsao-Wu US 2–5 154  Guided by 2011 NHLBI statement    27.6 17.0 30.8 NR   Weight management clinic patients 
         37.2 36.3 36.1 NR   Weight management clinic patients 
         34.8 38.4 35.2 NR   Weight management clinic patients 
Lennerz Germany 14–24 431  Any abnormal lipid    28 24 37 .02   Weight management program patients + some community 
Hadjiyannakis Canada 5–17 847  Any lipid abnormality 20   17 23 21 NR   Pediatric weight management program patients 

NHLBI, National Heart, Lung, and Blood Institute; NR, not reported; NS, not significant; OR, odds ratio.

Hemoglobin A1c

A total of 7 studies examined the prevalence of abnormal hemoglobin A1c (HbA1c),13,26,28,34,37,38,41  whereas 12 provided mean values for HbA1c.6,13,40,41,46,55,63,67,73,79,81,82  The participants in the 6 studies reporting abnormal HbA1c ranged in age from 3 to 19 years, with 1 study only reporting the mean age of 17 years (Table 10).26  This same study also deviated from the standard definitions of weight classification and defined an abnormal HBA1c level as greater than 6.5%, whereas the other 5 studies ranged from greater than 5.6% to 6%. One study did not report the sample size whereas others ranged in size from 101 to 8579. The prevalence of abnormal glucose in overall cohorts ranged from 1% to 17%, with the latter reported in a cohort of children 3 to 19 years of age. Using data from the National Health and Nutrition Examination Survey (NHANES) 1999 to 2012, 1 study cited a statistically significant difference between glucose levels among the overweight and obese groups (class I, II, and/or III obesity).38 

TABLE 10

Prevalence of Abnormal HbA1c (n = 7)

First AuthorCountryAges (y)NDefinition of AbnormalSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation Info
Skinner US 6–17 NR >5.7%  1.0 0.5 0.3 3.7   <.05   NHANES 2001–2002 
Salvatore US 3–18 101 >5.6    25 40.9 35.7 42.3 .873   Pediatric endocrinology patients 
O’Hara US 3–19 382 >5.7%  17  13 15 18 NS   Stage 3 pediatric weight management program patients 
Michalsky US Mean 17 242 >6.5%  6.1   3.7 [Typo] 4.2 NS  1: BMI 30–50, 2: 50–60, 3: >60 Bariatric surgery patients 
Skinner US 3–19 8579 >5.7%    1.87 3.40 6.38 13.19 <.001   NHANES 1999–2012 
Valery Australia 5–17 158 <6.0%   12    .539   Indigenous youth 
Hadjiyannakis Canada 5–17 847 >5.7%  15   13 15 16 NR   Pediatric weight management program patients 
First AuthorCountryAges (y)NDefinition of AbnormalSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation Info
Skinner US 6–17 NR >5.7%  1.0 0.5 0.3 3.7   <.05   NHANES 2001–2002 
Salvatore US 3–18 101 >5.6    25 40.9 35.7 42.3 .873   Pediatric endocrinology patients 
O’Hara US 3–19 382 >5.7%  17  13 15 18 NS   Stage 3 pediatric weight management program patients 
Michalsky US Mean 17 242 >6.5%  6.1   3.7 [Typo] 4.2 NS  1: BMI 30–50, 2: 50–60, 3: >60 Bariatric surgery patients 
Skinner US 3–19 8579 >5.7%    1.87 3.40 6.38 13.19 <.001   NHANES 1999–2012 
Valery Australia 5–17 158 <6.0%   12    .539   Indigenous youth 
Hadjiyannakis Canada 5–17 847 >5.7%  15   13 15 16 NR   Pediatric weight management program patients 

NR, not reported; NS, not significant.

Most studies of mean HbA1c values 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 = 11 348) included children with type 1 diabetes mellitus seen in an endocrine clinic; there were no differences in mean HbA1c by weight status.82  An additional study showed statistically significant, but very small, differences by weight category.55 

TABLE 11

Mean HbA1c (n = 12)

First AuthorCountryAges (y)NUnitsSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation Info
Bell Australia 6–13 283   4.96 4.97 5.16   .053    
Watts Australia 6–13 148   4.9 4.9 4.9   NS  Assume CDC  
Turchiano USA 14–18 1185    5.43 5.35 5.4   <.05   Youth of urban minoritized groups 
Puri USA 10–18 198    5.4 5.5    NS   Youth of minoritized groups 
McCarthy USA 11–14 199   4.60 4.66 4.65   NS   Children of minoritized groups 
Redondo USA 2–17 11 348 2–5 y  8.2 8.1 8.2   .75   Patients with type 2 diabetes mellitus 
     6–12 y  8.3 8.4 8.4   .43    
     13–17 y  8.8 8.8 8.8   .03    
Bocca Netherlands 3–5 75 %, median  5.3  5.3 5.4       
Valery Australia 5–17 158   5.39 5.55    .037   Indigenous youth 
Hadjiyannakis Canada 5–17 847  5.3   5.3 5.3 5.4 NR   Pediatric weight management program patients 
Kloppenberg Denmark Median 12 3978 mmol/mol Males  34 33.92 34.24   <.001 P value includes differences by sex HW: <90th, OW: 90th–99th, OB: >99th Weight management clinic + population-based 
     Females  33.7 34 34.18   <.001 P value includes differences by sex HW: <90th, OW: 90th–99th, OB: >99th Weight management clinic + population-based 
Lennerz Germany 14–24 431     5.24 5.37 5.48 .01   Weight management + some community 
Seth USA Mean 13 767    5.1 5.2 5.2 5.3 .14   Steatohepatitis clinic patients 
First AuthorCountryAges (y)NUnitsSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation Info
Bell Australia 6–13 283   4.96 4.97 5.16   .053    
Watts Australia 6–13 148   4.9 4.9 4.9   NS  Assume CDC  
Turchiano USA 14–18 1185    5.43 5.35 5.4   <.05   Youth of urban minoritized groups 
Puri USA 10–18 198    5.4 5.5    NS   Youth of minoritized groups 
McCarthy USA 11–14 199   4.60 4.66 4.65   NS   Children of minoritized groups 
Redondo USA 2–17 11 348 2–5 y  8.2 8.1 8.2   .75   Patients with type 2 diabetes mellitus 
     6–12 y  8.3 8.4 8.4   .43    
     13–17 y  8.8 8.8 8.8   .03    
Bocca Netherlands 3–5 75 %, median  5.3  5.3 5.4       
Valery Australia 5–17 158   5.39 5.55    .037   Indigenous youth 
Hadjiyannakis Canada 5–17 847  5.3   5.3 5.3 5.4 NR   Pediatric weight management program patients 
Kloppenberg Denmark Median 12 3978 mmol/mol Males  34 33.92 34.24   <.001 P value includes differences by sex HW: <90th, OW: 90th–99th, OB: >99th Weight management clinic + population-based 
     Females  33.7 34 34.18   <.001 P value includes differences by sex HW: <90th, OW: 90th–99th, OB: >99th Weight management clinic + population-based 
Lennerz Germany 14–24 431     5.24 5.37 5.48 .01   Weight management + some community 
Seth USA Mean 13 767    5.1 5.2 5.2 5.3 .14   Steatohepatitis clinic patients 

HW, healthy weight; NR, not reported; NS, not significant ; OB, obese; OW, overweight.

Glucose

A total of 37 studies examined the prevalence of abnormal glucose,5,6,814,1723,25,26,2832, 3742,71,77,78,80,8486  whereas 39 provided mean values for glucose.5,6,8,10,13,18,22,32,35,36,40,41,43,44, 4649,52,5456,5862,65,66,68,70,71,7375  Thirty-seven studies reported prevalence of abnormal glucose across weight groups in cohorts ranging from 3 to 19 years of age (Table 12). Twelve of these studies reported significant differences, with 9 of these studies including a healthy group comparator. Of those studies indicating significant differences, prevalence sharply increased across increasing weight category, including a multifold higher prevalence in youth with obesity versus those with healthy weight. Eight studies reported data from nationally representative datasets, including in the United States and Korea, with 5 of these studies reporting significant differences in prevalence across weight categories.

Prevalence of abnormal glucose in overall cohorts ranged from 0% to 26.1%, with the latter reported in a cohort of adolescents undergoing 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 abnormal glucose. Seven studies reported prevalence separately by biological sex, although there were no consistent differences, with males having higher prevalence in 4 studies and females having higher prevalence in 2 studies. Importantly, studies varied in definition of abnormal glucose, with 18 studies using the threshold of ≥100 mg/dL, 7 studies using the threshold of ≥110 mg/dL, and 2 studies using the threshold of ≥126 mg/dL.

Thirty-nine studies reported mean glucose levels across weight groups in cohorts ranging from 3 to 20 years of age, with 12 studies detecting significant differences (Table 13). Eight of these studies included a healthy weight comparator, whereas 4 demonstrated significant differences in glucose levels among the overweight and obese (class I, II, and/or III obesity) groups. Significant differences in mean glucose level across weight groups were observed in multiple age ranges, including studies that consisted of both children and adolescents, as well as a study of exclusively preschool-aged children.46  However, none of the subgroups had a mean glucose value above the standard threshold of ≥100 mg/dL (≥5.5 mmol/L) to indicate elevated fasting glucose.

Insulin

A total of 14 studies examined the prevalence of abnormal insulin,6,9,12,19,2224,26,28,34,39,41,42,84  whereas 32 provided mean values for insulin.6,8,22,24,32,35,36,4044,46, 47,49,52,54,55,5862,65,66,70,71,73,75,84,87,88 Table 14 indicates that 8 of 12 studies observed significant differences in prevalence of abnormal insulin across weight categories, with a range of 0% in a sample of 3- to 18-year-old participants who were overweight in the United States34  to 80% among 9- to 16-year-old participants with obesity in Canada.19  Prevalence estimates were reported from samples enrolled in the United States (8 studies), 2 studies each in Australia and Canada, and 1 study each in Italy and Japan; however, none of the studies were indicated as nationally representative. Eight studies had less than 500 participants, but the sample sizes ranged from 62 to 6358. Three studies enrolled participants from clinic-based settings, including a pediatric gastroenterology clinic, a pediatric weight management program, and a bariatric surgery program. Several definitions of abnormal insulin were used, making it difficult to compare actual prevalence estimates across studies. In several studies, youth with obesity had a four- to fivefold higher prevalence of abnormal insulin compared with youth with healthy weight. There were also differences observed within obesity classification: for example, youth with class II or higher obesity had a threefold higher prevalence of abnormal insulin than their peers with class I obesity.22  One study that did not observe significant differences in abnormal insulin prevalence across weight categories comprised patients who were all enrolled in a bariatric surgery program, so patients had comorbidities at the time of entry.26  The 1 study that examined abnormal insulin prevalence by age did not observe differences between 6- to 11-year-old versus 12- to 19-year-old youth.24  Three studies reported prevalence stratified by biological sex; in 2 of the studies, females had higher prevalence of abnormal insulin compared with males.

TABLE 12

Prevalence of Abnormal Glucose (n = 31)

First AuthorCountryAges (y)NDefinition of AbnormalSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation 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   1.3 5.3   .037    
Valerio Italy 3–16 150 110–126 mg/dL       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 Rico) 12–18 101 >100 mg/dL   1.9 1.9    1.0    
O’Hara USA 3–19 382 ≥100 mg/dL   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, 2: 50 < 60; 3: >60 Bariatric surgery patients 
Yoshinaga Japan 6–12 471 >100 Males   0.9 2.0       
     Females   6.7       
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    
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 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: 12.30 12–14: 9.61 12–14: 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      .829   Indigenous youth 
Avnieli Velfer Israel 2–18 1027 >100 mg/dL Males       NR  OB 95th, SO 120%/95th Obesity clinic patients 
     Females       NR  OB 95th, SO 120%/95th Obesity clinic patients 
Fyfe-Johnson USA 8–17 300 >100 mg/dL       Clinic patients 
Gunes USA 11–18 363 >100 mg/dL Males   21.2 14.5   .867   Adolescent clinic patients 
     Females   11.2 13.9   .493   Adolescent clinic patients 
Hadjiyannakis Canada 5–17 847 >6.1 mmol/L    NR   Pediatric weight management program patients 
Lennerz Germany 14–24 431 >110 mg/dL     19 20 .005   Weight management clinic patients + some community 
Stolzman USA 12–17 62 >100 mg/dL      NR   Community recruitment 
First AuthorCountryAges (y)NDefinition of AbnormalSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation 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   1.3 5.3   .037    
Valerio Italy 3–16 150 110–126 mg/dL       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 Rico) 12–18 101 >100 mg/dL   1.9 1.9    1.0    
O’Hara USA 3–19 382 ≥100 mg/dL   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, 2: 50 < 60; 3: >60 Bariatric surgery patients 
Yoshinaga Japan 6–12 471 >100 Males   0.9 2.0       
     Females   6.7       
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    
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 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: 12.30 12–14: 9.61 12–14: 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      .829   Indigenous youth 
Avnieli Velfer Israel 2–18 1027 >100 mg/dL Males       NR  OB 95th, SO 120%/95th Obesity clinic patients 
     Females       NR  OB 95th, SO 120%/95th Obesity clinic patients 
Fyfe-Johnson USA 8–17 300 >100 mg/dL       Clinic patients 
Gunes USA 11–18 363 >100 mg/dL Males   21.2 14.5   .867   Adolescent clinic patients 
     Females   11.2 13.9   .493   Adolescent clinic patients 
Hadjiyannakis Canada 5–17 847 >6.1 mmol/L    NR   Pediatric weight management program patients 
Lennerz Germany 14–24 431 >110 mg/dL     19 20 .005   Weight management clinic patients + some community 
Stolzman USA 12–17 62 >100 mg/dL      NR   Community recruitment 

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

TABLE 13

Mean Glucose (n = 39)

First AuthorCountryAges (y)NUnitsSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation 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 = 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 = 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    
Perichart-Perera Mexico 9–12 88 mg/dL   75.30 77.13 75.91   NS    
Perez USA (Puerto Rico) 12–18 101 mg/dL   85.4 86.4    .40    
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    
Botton France 8–17 452 mmol/L Males 4.76 4.75 4.82    NS    
     Females 4.65 4.63 4.80    NS    
Serap Turkey 6–16 284 mg/dL Males  92.1  92.4   NS   Pediatric endocrinology patients 
     Females  92.6  92.2   NS    
Del- Rio-Navarro Mexico 6–13 1819 mg/dL Males  79.5 82.1 83.0   <.05    
     Females  77.2 78.7 79.8   <.05    
Valery Australia 5–17 158 mmol/L   4.66 4.89    .318   Indigenous youth 
Avnieli Velfer Israel 2–18 1027 mg/dL Males    90 90  .93  OB 95th, SO 120%/95th Obesity clinic patients 
     Females    84 91  .04    
Hadjiyannakis Canada 5–17 847 mmol/L  4.90   4.80 4.90 4.90 NR   Pediatric weight management program patients 
Kim Korea 12–13 120 mg/dL   90.0 90.0    .707   School based 
Kloppenberg Denmark Median 12 3978 mmol/L Males  5.0 5.1 5.2   <.005 P value includes differences by sex HW: <90th, OW: 90th–99th, OB: >99th Weight management clinic patients + population-based 
     Females  5.0 5.0 5.1   0.005    
Sougawa Japan 12–18 1679 mg/dL Males 89.3 89.0 90.7    .014   Schools 
     Females 88.0 87.9 88.8    .215    
First AuthorCountryAges (y)NUnitsSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation 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 = 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 = 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    
Perichart-Perera Mexico 9–12 88 mg/dL   75.30 77.13 75.91   NS    
Perez USA (Puerto Rico) 12–18 101 mg/dL   85.4 86.4    .40    
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    
Botton France 8–17 452 mmol/L Males 4.76 4.75 4.82    NS    
     Females 4.65 4.63 4.80    NS    
Serap Turkey 6–16 284 mg/dL Males  92.1  92.4   NS   Pediatric endocrinology patients 
     Females  92.6  92.2   NS    
Del- Rio-Navarro Mexico 6–13 1819 mg/dL Males  79.5 82.1 83.0   <.05    
     Females  77.2 78.7 79.8   <.05    
Valery Australia 5–17 158 mmol/L   4.66 4.89    .318   Indigenous youth 
Avnieli Velfer Israel 2–18 1027 mg/dL Males    90 90  .93  OB 95th, SO 120%/95th Obesity clinic patients 
     Females    84 91  .04    
Hadjiyannakis Canada 5–17 847 mmol/L  4.90   4.80 4.90 4.90 NR   Pediatric weight management program patients 
Kim Korea 12–13 120 mg/dL   90.0 90.0    .707   School based 
Kloppenberg Denmark Median 12 3978 mmol/L Males  5.0 5.1 5.2   <.005 P value includes differences by sex HW: <90th, OW: 90th–99th, OB: >99th Weight management clinic patients + population-based 
     Females  5.0 5.0 5.1   0.005    
Sougawa Japan 12–18 1679 mg/dL Males 89.3 89.0 90.7    .014   Schools 
     Females 88.0 87.9 88.8    .215    

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

TABLE 14

Prevalence of Abnormal Insulin (n = 14)

First AuthorCountryAges (y)NDefinition of AbnormalSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation Info
Bell Australia 6–13 283 >12 mIU/L   8.0 19.5 38.9   <.001    
Salvatore USA 3–18 101 >10    47.4 56.5 72.2 .301   Pediatric gastroenterology patients 
O’Hara USA 3–19 382 >20 mIU/mL  42  29 34 40 57 NS   Stage 3 pediatric weight management program patients 
Marcus USA Mean 11.2 1305 >30     10.5 35.7  <.0001    
Michalsky USA 13–19 242 >17.0 ulU/mL  74.1   73.9 74.0 75.0 >.99  1: 30 < 50 BMI, 2: 50 < 60; 3: >60 Bariatric surgery patients 
Yoshinaga Japan 6–12 471 >90th Males 20.5 47.7     <.05    
     Females   45 60.8   <.05    
Maximova Canada 6–11 2087 >75th 6–11 y  18.0 50.2    NR    
     12–19 y  11.6 49.3    NR    
Baranowski USA Mean 13.6 1740 >30 uU/mL  36.2 16.0 36.2 72.3   NR    
Caserta Italy 11–13 646 >11 males, >13.2 females Males  12.4 25.6 60.4   <.05    
     Females  11.2 38.2 65.5   <.05    
Marcus USA Mean 11.8 6358 >30 uU/mL   0.8 3.0 13.4  40.0 <.001    
Lambert Canada 9–16 3613 >38 9 y, >60 13–16 y Males  11.3 37.2 72.1   <.0001    
     Females  23.2 46.3 80.1   <.0001    
Valery Australia 5–17 158 <15.0 mU/L   30 56    .021   Indigenous youth 
Gunes USA 11–18 363 >30 uU/mL Males   6.6 12.8   .347   Adolescent clinic patients 
     Females   1.7 24.5   <.001   Adolescent clinic patients 
Stolzman USA 12–17 62 >15 uU/mL    33   <.05   Community recruitment 
First AuthorCountryAges (y)NDefinition of AbnormalSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation Info
Bell Australia 6–13 283 >12 mIU/L   8.0 19.5 38.9   <.001    
Salvatore USA 3–18 101 >10    47.4 56.5 72.2 .301   Pediatric gastroenterology patients 
O’Hara USA 3–19 382 >20 mIU/mL  42  29 34 40 57 NS   Stage 3 pediatric weight management program patients 
Marcus USA Mean 11.2 1305 >30     10.5 35.7  <.0001    
Michalsky USA 13–19 242 >17.0 ulU/mL  74.1   73.9 74.0 75.0 >.99  1: 30 < 50 BMI, 2: 50 < 60; 3: >60 Bariatric surgery patients 
Yoshinaga Japan 6–12 471 >90th Males 20.5 47.7     <.05    
     Females   45 60.8   <.05    
Maximova Canada 6–11 2087 >75th 6–11 y  18.0 50.2    NR    
     12–19 y  11.6 49.3    NR    
Baranowski USA Mean 13.6 1740 >30 uU/mL  36.2 16.0 36.2 72.3   NR    
Caserta Italy 11–13 646 >11 males, >13.2 females Males  12.4 25.6 60.4   <.05    
     Females  11.2 38.2 65.5   <.05    
Marcus USA Mean 11.8 6358 >30 uU/mL   0.8 3.0 13.4  40.0 <.001    
Lambert Canada 9–16 3613 >38 9 y, >60 13–16 y Males  11.3 37.2 72.1   <.0001    
     Females  23.2 46.3 80.1   <.0001    
Valery Australia 5–17 158 <15.0 mU/L   30 56    .021   Indigenous youth 
Gunes USA 11–18 363 >30 uU/mL Males   6.6 12.8   .347   Adolescent clinic patients 
     Females   1.7 24.5   <.001   Adolescent clinic patients 
Stolzman USA 12–17 62 >15 uU/mL    33   <.05   Community recruitment 

NR, not reported; NS, not significant.

Thirty of the 32 studies (Table 15) reporting mean values of insulin observed significant differences across weight categories; the other 2 studies did not statistically test for differences among weight categories. Although most (22 of 32) studies examined differences between 2 weight categories (healthy versus combined overweight and obese), 10 of the 32 studies reported mean insulin values for at least 3 weight categories; in every case, there was a noticeable dose-gradient relationship of insulin across the multiple weight categories and the P value was significant. These differences were noted among healthy versus overweight versus obesity groups as well as a study of adolescents that observed differences among healthy, overweight, obesity class I, and obesity class II+.24  Most of the cohorts spanned the age range from childhood to adolescence, although 1 study observed significant differences in insulin values among 3- to 5-year-old children who were overweight versus those who had obesity,46  and a second study also observed significant differences among 6- to 8-year-old children with healthy weight versus those with obesity.52  Two studies reported mean values by age24,71 ; in both cases, the insulin levels were higher in adolescents versus children, and the insulin values were noticeably higher among the youth with higher weight status.

TABLE 15

Mean Insulin (n = 32)

First AuthorCountryAges (Y)NUnitsSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight definitionsPopulation Info
Bonet Spain Mean = 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 = 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 = 11 115 uU/mL   6.6  14.5   <.001    
Salawi Canada 6–19 345 μ/L    18.5   31.3 .02   Patients referred to pediatric weight management program 
Rank Germany 6–19 463 μ/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 μ/l Males  4.99  10.38   <.001    
     Females  5.41  12.21   <.001    
Marcus USA Mean = 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    
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 = 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 μ/L   8.55 10.2 12.2   <.001    
Norris USA Mean = 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 μ/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 differences by sex HW: <90th, OW: 90th–99th, OB: >99th Weight management clinic patients + population-based 
     Females  62.2 85.4 122.8   <.001 P value includes differences by sex HW: <90th, OW: 90th–99th, OB: >99th Weight management clinic patients + population-based 
First AuthorCountryAges (Y)NUnitsSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight definitionsPopulation Info
Bonet Spain Mean = 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 = 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 = 11 115 uU/mL   6.6  14.5   <.001    
Salawi Canada 6–19 345 μ/L    18.5   31.3 .02   Patients referred to pediatric weight management program 
Rank Germany 6–19 463 μ/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 μ/l Males  4.99  10.38   <.001    
     Females  5.41  12.21   <.001    
Marcus USA Mean = 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    
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 = 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 μ/L   8.55 10.2 12.2   <.001    
Norris USA Mean = 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 μ/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 differences by sex HW: <90th, OW: 90th–99th, OB: >99th Weight management clinic patients + population-based 
     Females  62.2 85.4 122.8   <.001 P value includes differences by sex HW: <90th, OW: 90th–99th, OB: >99th Weight management clinic patients + population-based 

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

HOMA-IR

A total of 10 studies examined the prevalence of abnormal homeostatic model assessment for insulin resistance (HOMA-IR),7,9,12,26,32,35, 40,71,88,89  whereas 25 provided mean values for HOMA-IR.7,32,35,36,40,41,43, 45,46,49,52,54,58,59,6163,65,66,70,71,73,75, 81,90  Prevalence of abnormal HOMA-IR ranged from 0% in healthy adolescents71  to 70.8% in adolescents with class III obesity who were enrolled in a bariatric surgery program26  (Table 16). However, definitions of abnormal HOMA-IR differed in every study, so it is difficult to compare prevalence estimates. Prevalence was reported for cohorts from the United States (5 studies) and Europe (5 studies); however, none were indicated as nationally representative cohorts. Prevalence of abnormal HOMA-IR was significantly different across weight categories in 7 of the 9 studies; 1 study did not statistically examine differences across weight categories and another study did not observe differences, but the sample only consisted of adolescents with obesity who were undergoing bariatric surgery (with no differences among class I, class II, or class III obesity; Michalsky/US).26  One study reported prevalence by age group with a stark difference in abnormal HOMA-IR in both children and adolescents with obesity (approximately 41%) versus participants with healthy weight (0% to 3%) (Valerio/Italy).71  Two studies reported prevalence stratified by biological sex; in both cases, prevalence of abnormal HOMA-IR was higher among females compared with males (Caserta/Italy; Serap/Turkey).9,35 

TABLE 16

Prevalence of Abnormal HOMA-IR (n = 10)

First AuthorCountryAges (y)NDefinition of AbnormalSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight definitionsPopulation Info
Bindler USA 11–14 151 >2.7 No  22.7  62.5   <.001    
Valerio Italy 3–16 150 >2.5 children; >4.0 adolescents Children   40.8   <.001    
     Adolescents   41.2   <.002    
Turchiano USA 14–18 1185 >3.99   4.5 12.4 37.8   <.001   Youth of urban minoritized groups 
Perez US (Puerto Rico) 12–18 101 ≥3.16   35.6 81.3    <.001    
Peplies Europe 3–10.9 3348 >95th  17.8 10.9 36.5 66.7       
Michalsky USA 13–19 242 ≥4.0  71.1   71.2 71.2 70.8 >.99  1: 30 < 50 BMI, 2: 50 < 60; 3: >60 Bariatric surgery patients 
Caserta Italy 11–13 646 >2.28 males, >2.67 females Males  13.1 26.7 54.7   <.05    
     Females  11.8 37.1 65.5   <.05    
Serap Turkey 6–16 284 >2.5 Males  3.8  47.2   <.001   Pediatric endocrinology patients 
     Females  8.6  56.7   <.001    
Manios Greece 10–12 522 >2.10 (97.5th %ile of NW) No 9.2 2.9 10.5 31.0   <.001    
Gunes USA 11–18 363 3.16 Males   60 68   .402   Adolescent clinic patients 
     Females   48.2 44.7   <.001   Adolescent clinic patients 
First AuthorCountryAges (y)NDefinition of AbnormalSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight definitionsPopulation Info
Bindler USA 11–14 151 >2.7 No  22.7  62.5   <.001    
Valerio Italy 3–16 150 >2.5 children; >4.0 adolescents Children   40.8   <.001    
     Adolescents   41.2   <.002    
Turchiano USA 14–18 1185 >3.99   4.5 12.4 37.8   <.001   Youth of urban minoritized groups 
Perez US (Puerto Rico) 12–18 101 ≥3.16   35.6 81.3    <.001    
Peplies Europe 3–10.9 3348 >95th  17.8 10.9 36.5 66.7       
Michalsky USA 13–19 242 ≥4.0  71.1   71.2 71.2 70.8 >.99  1: 30 < 50 BMI, 2: 50 < 60; 3: >60 Bariatric surgery patients 
Caserta Italy 11–13 646 >2.28 males, >2.67 females Males  13.1 26.7 54.7   <.05    
     Females  11.8 37.1 65.5   <.05    
Serap Turkey 6–16 284 >2.5 Males  3.8  47.2   <.001   Pediatric endocrinology patients 
     Females  8.6  56.7   <.001    
Manios Greece 10–12 522 >2.10 (97.5th %ile of NW) No 9.2 2.9 10.5 31.0   <.001    
Gunes USA 11–18 363 3.16 Males   60 68   .402   Adolescent clinic patients 
     Females   48.2 44.7   <.001   Adolescent clinic patients 

NW, normal weight.

Studies reporting mean HOMA-IR across weight categories (Table 17) corroborated the findings of the prevalence of abnormal HOMA-IR. Twenty-three of the 25 studies reported significant differences in HOMA-IR value across weight categories. Most of these studies examined differences between healthy weight versus overweight and obesity combined. However, 6 studies examined differences across 3 weight categories, showing a gradient of HOMA-IR values among healthy weight, overweight, and obesity. One study reported mean values separately by age group, with adolescents having higher HOMA-IR values than children in both the healthy weight and obesity categories.71  Four studies reported mean HOMA-IR values stratified by sex; there was not a consistent pattern in differing values between females and males.

TABLE 17

Mean HOMA-IR (n = 25)

First AuthorCountryAges (y)NSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight definitionsPopulation Info
Aylanc Turkey Mean = 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 = 10.8 115   1.38  3.11   <.001    
Salawi Canada 6–19 345    4.0   6.8 .03   Patients referred to 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    
    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 = 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 = 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 + some community 
Kim Korea 12–13 120   2.0 3.2    <.001   School based 
First AuthorCountryAges (y)NSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight definitionsPopulation Info
Aylanc Turkey Mean = 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 = 10.8 115   1.38  3.11   <.001    
Salawi Canada 6–19 345    4.0   6.8 .03   Patients referred to 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    
    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 = 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 = 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 + some community 
Kim Korea 12–13 120   2.0 3.2    <.001   School based 

HW, healthy weight.

Most cohorts included both children and adolescents or only adolescents; however, the 1 cohort that did include young children (ages 3–5 years) did not observe a significant differences in HOMA-IR across weight categories.46  A cohort of children ages 6 to 8 years did observe significantly higher HOMA-IR values among children with obesity versus children with healthy weight.52 

Other Glucose Metabolism

Additional studies reported the prevalence of prediabetes (n = 3),13,85,91  diabetes mellitus (n = 8),13,26,33,71,83,85,87,92  and metabolic syndrome (n = 16).10,11,14, 17,20,2932,35,42,49,9396  Three studies reported prevalence of prediabetes (Table 18). The population-based study in Mexico defined prediabetes as 2-hour glucose tolerance test result of 140 to 200 mg/dL. Prediabetes was higher in children with overweight or obesity versus children with healthy weight.85  A second population-based Canadian study showed greater risk of prediabetes for children with obesity versus children with healthy weight.91 

TABLE 18

Prevalence of Prediabetes (n = 3)

First AuthorCountryAges (y)NSubgroup (eg, M/F)Definition of AbnormalTotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation Info
Guerrero-Romero Mexico 6–18 1534  140–200 2-h glucose  1.4 3.5 5.7       
Rodd Canada 6–19 3449  Canadian Diabetes Association  Ref  aOR = 1.53   <.05  WHO Population based 
Hadjiyannakis Canada 5–17 847  >6.1 FPG or >7.8 OGTT   NR   Pediatric weight management program patients 
First AuthorCountryAges (y)NSubgroup (eg, M/F)Definition of AbnormalTotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation Info
Guerrero-Romero Mexico 6–18 1534  140–200 2-h glucose  1.4 3.5 5.7       
Rodd Canada 6–19 3449  Canadian Diabetes Association  Ref  aOR = 1.53   <.05  WHO Population based 
Hadjiyannakis Canada 5–17 847  >6.1 FPG or >7.8 OGTT   NR   Pediatric weight management program patients 

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

The 8 studies reporting the prevalence of diabetes (Table 19) used varying definitions of diabetes, based on fasting plasma glucose, glucose tolerance tests, HbA1c, diagnosis, or use of medications. Most studies showed significantly higher prevalence of diabetes among children with obesity or severe obesity, although overall prevalence was low. Prevalence of diabetes >3% was seen only in a pediatric endocrinology clinic33  and among bariatric surgery candidates.26 

TABLE 19

Prevalence of Diabetes (n = 8)

First AuthorCountryAges (y)NDefinition of AbnormalSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation Info
Valerio Italy 3–16 150 FPG > 126 mg/dL or 2-h >200 mg/dL         
Propst USA Mean 12.7 1111 >6.4     39.8  52.4 <.001   Pediatric endocrinology patients 
Michalsky USA 13–19 242 Diagnosis, medication, A1c ≥6.5%, FPG ≥126 mg/dL; or 2-h OGTT ≥200 mg/dL  13.6   11.3 15.6 16.0 .55  1: 30 < 50 BMI, 2: 50 < 60; 3: >60 Bariatric surgery patients 
Weiss USA 12–17 1418 ADA definitions   0.028985507 0.022452504  <.001    
Bar Dayan Israel 17 76732 Type 2 Males 0.036% 0.02% 0.05% 0.4%  0% <.001   Military recruits 
     Females 0.01% 0.001% 0.03% 0.1%  0% .015    
Guerrero-Romero Mexico 6–18 1534 ≥200 mg/dL 2-h postload  0.6 0.0 0.5 1.3       
Hadjiyannakis Canada 5–17 847 >7.0 FPG, >11.0 OGTT    NR   Pediatric weight management program patients 
Tsao-Wu USA 2–5 154 HgA1c >6.5%     NR   Weight management clinic patients 
  6–11 880      1.0 4.0 4.0 NR   Weight management clinic patients 
  12–17 1004      2.0 1.4 6.2 NR   Weight management clinic patients 
First AuthorCountryAges (y)NDefinition of AbnormalSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation Info
Valerio Italy 3–16 150 FPG > 126 mg/dL or 2-h >200 mg/dL         
Propst USA Mean 12.7 1111 >6.4     39.8  52.4 <.001   Pediatric endocrinology patients 
Michalsky USA 13–19 242 Diagnosis, medication, A1c ≥6.5%, FPG ≥126 mg/dL; or 2-h OGTT ≥200 mg/dL  13.6   11.3 15.6 16.0 .55  1: 30 < 50 BMI, 2: 50 < 60; 3: >60 Bariatric surgery patients 
Weiss USA 12–17 1418 ADA definitions   0.028985507 0.022452504  <.001    
Bar Dayan Israel 17 76732 Type 2 Males 0.036% 0.02% 0.05% 0.4%  0% <.001   Military recruits 
     Females 0.01% 0.001% 0.03% 0.1%  0% .015    
Guerrero-Romero Mexico 6–18 1534 ≥200 mg/dL 2-h postload  0.6 0.0 0.5 1.3       
Hadjiyannakis Canada 5–17 847 >7.0 FPG, >11.0 OGTT    NR   Pediatric weight management program patients 
Tsao-Wu USA 2–5 154 HgA1c >6.5%     NR   Weight management clinic patients 
  6–11 880      1.0 4.0 4.0 NR   Weight management clinic patients 
  12–17 1004      2.0 1.4 6.2 NR   Weight management clinic patients 

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

Of the 16 studies assessing the prevalence of metabolic syndrome (Table 20), the largest sample size was 4450 and the smallest sample was 101. Seven studies reported the prevalence of metabolic syndrome as the presence of 3 or more components of metabolic syndrome in cohorts ranging from 6 to 24 years of age, with 3 of the studies conducted in the United States. The remainder of the studies (8) reported the presence of metabolic syndrome using the following criteria: Adult Treatment Panel (ATP) III (2 studies), NCEP ATP III (2 studies), 3 components plus risks (2 studies), 3 components plus abnormalities (1 study), and International Diabetes Foundation (IDF) (1 study). Of the 16 studies, 14 included a healthy weight comparison, and 11 of the studies reported a significant association between the prevalence of metabolic syndrome and overweight. Of the studies that defined the presence of metabolic syndrome as having 3 or more components and compared prevalence across children with normal weight, overweight, and obesity, the prevalence of metabolic syndrome ranged from 0% to 4.7% among children with healthy weight and increased to 14.5% to 35% among children and adolescents with class I obesity. Of the 2 studies that defined metabolic syndrome as ATP III and compared prevalence across children with healthy weight, overweight, and obesity, the prevalence of metabolic syndrome ranged from 0.3% to 1.6%, which increased to 39% for children with class I obesity in 1 study. One of the 2 studies did not report prevalence for class I obesity. Of the 2 studies that defined metabolic syndrome as NCEP ATP III and compared prevalence across children with healthy weight, overweight, and obesity, the prevalence of metabolic syndrome ranged from ranged from 1% to 1.5%, which increased to 28.6% to 41% for children with class 1 obesity. Of the 2 studies that defined metabolic syndrome using 3 components plus risk and compared prevalence across children with healthy weight, overweight, and obesity, the reported prevalence of metabolic syndrome ranged from 0% to 0.8% for females and 1.7% for males, which increased to 1.6% to 24.6% for female children and 35% for male children with class 1 obesity. One study defined metabolic syndrome as 3 components plus abnormalities and the reported prevalence across children with healthy weight, overweight, and obesity was 0.2% among children with healthy weight and 25.6% among children and adolescents with class 1 obesity. When using the IDF definition of metabolic syndrome, the reported prevalence was 1.6% among children with healthy weight and 28% among children and adolescents with class 1 obesity. In addition, 3 studies reported statistical comparisons by biological sex. However, only 1 supported a significant relationship between metabolic syndrome and unhealthy weight status for both males and females. Prevalence comparisons were not available within studies for different age subgroups.

TABLE 20

Prevalence of Metabolic Syndrome (n = 16)

First AuthorCountryAges (y)NDefinition of abnormalSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation Info
Kim Korea 10–19 931 3+ components  6.4 1.7 9.4 35.0   <.0001    
Halley Castillo Mexico 7–24 1366 3+ components   4.7 52.8    <.000    
Galera-Martinez Spain 12–16.9 379 NCEP ATP III  5.7% 1.5% 12.0% 28.6%   <.001    
Duncan USA 12–19 991 3+ components  6.4 7.1 32.1   <.001   NHANES 
Davis USA 7–18 211 NCEP ATP III   15 41   <.001   Patients in rural Georgia 
Vissers Belgium 16–19 506 ATP III  4.1% 0.3% 2.8% 39.1%   <.001    
Ryu Korea 12–13 1393 ATP III Males 6.1 1.6 21.3    <.001    
     Females 5.0 1.6 22.3    <.001    
Perez US (Puerto Rico) 12–18 101 3+ components   35.4    <.001    
Yoshinaga Japan 6–12 471 3+ components Males   8.9 16.2       
     Females   8.3 20.6       
Park Korea 10–19 1554 3+ components   0.0 2.8 23.7   <.05   2007–2008 KNHANES 
Laurson USA 12–18.9 3385 3+ risks Males 7.9 0.8 6.8 35.4   NR   NHANES 
     Females 6.7 1.7 9.2 24.6   NR    
Cizmecioglu Turkey 10–19 310 IDF  1.6  5.5 28.1   NR    
Park Korea 12–19 664 3+ abnormalities   0.2 5.8 25.6       
Serap Turkey 6–16 284 3+ risks    1.6      Pediatric endocrinology patients 
Pan USA 12–19 4450 3+ components   0.9 2.1 14.5   <.0001 OB   NHANES 1999–2002 
Bacopoulou Greece 12–17 1578 IDF criteria  2.6 0.1 2.9 31.6     IOTF thresholds School 
First AuthorCountryAges (y)NDefinition of abnormalSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation Info
Kim Korea 10–19 931 3+ components  6.4 1.7 9.4 35.0   <.0001    
Halley Castillo Mexico 7–24 1366 3+ components   4.7 52.8    <.000    
Galera-Martinez Spain 12–16.9 379 NCEP ATP III  5.7% 1.5% 12.0% 28.6%   <.001    
Duncan USA 12–19 991 3+ components  6.4 7.1 32.1   <.001   NHANES 
Davis USA 7–18 211 NCEP ATP III   15 41   <.001   Patients in rural Georgia 
Vissers Belgium 16–19 506 ATP III  4.1% 0.3% 2.8% 39.1%   <.001    
Ryu Korea 12–13 1393 ATP III Males 6.1 1.6 21.3    <.001    
     Females 5.0 1.6 22.3    <.001    
Perez US (Puerto Rico) 12–18 101 3+ components   35.4    <.001    
Yoshinaga Japan 6–12 471 3+ components Males   8.9 16.2       
     Females   8.3 20.6       
Park Korea 10–19 1554 3+ components   0.0 2.8 23.7   <.05   2007–2008 KNHANES 
Laurson USA 12–18.9 3385 3+ risks Males 7.9 0.8 6.8 35.4   NR   NHANES 
     Females 6.7 1.7 9.2 24.6   NR    
Cizmecioglu Turkey 10–19 310 IDF  1.6  5.5 28.1   NR    
Park Korea 12–19 664 3+ abnormalities   0.2 5.8 25.6       
Serap Turkey 6–16 284 3+ risks    1.6      Pediatric endocrinology patients 
Pan USA 12–19 4450 3+ components   0.9 2.1 14.5   <.0001 OB   NHANES 1999–2002 
Bacopoulou Greece 12–17 1578 IDF criteria  2.6 0.1 2.9 31.6     IOTF thresholds School 

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

Systolic Blood Pressure

A total of 21 studies examined the prevalence of abnormal systolic blood pressure (SBP),5,7,8,10,13,15,18, 19,24,3539,63,97101  whereas 52 provided mean values for SBP.5,7,8,10,13,18,22,24,32,33,35,36,39,40, 4246,4850,5456,5966,68,7175,77,79,83, 90,97,99,102108  Twenty-one studies, including children ages 3 to 19 years, examined the prevalence of elevated SBP in relation to excess weight (Table 21). Within the 17 studies formally testing such an association, 14 included a healthy weight comparison group, and all but 1 of these reported a significant association between the prevalence of elevated SBP and overweight or obesity.

TABLE 21

Prevalence of Abnormal Systolic Blood Pressure (n = 21)

First AuthorCountryAges (y)NDefinition of AbnormalSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation Info
Ice USA 9–13 29286 >95th   7.9 13.4 23.4   <.01   Appalachian population 
Davis USA 7–18 211 (160 for lipids) >90th   16 45   <.001   Rural Georgia 
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    13.3   <.001  OB >97th  
Puri USA 10–18 198 >95th   28    .002   General pediatrics and endocrinology patients 
Maggio Switzerland Mean 8.8 66 >95th    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    
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 = 3.8 OR = 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 = 1.0 OR = 2.50 OR = 4.31   <.05    
     Females 3.8 OR = 1.0 OR = 3.39 OR = 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       
     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, SO 120%/95th Obesity clinic patients 
     Females    32.4 46.6  <.001  OB 95th, SO 120%/95th Obesity clinic patients 
Hadjiyannakis Canada 5–17 847 >95th  14   10 26 NR   Pediatric weight management program patients 
Stolzman USA 12–17 62 >90th    13   NS   Community recruitment 
First AuthorCountryAges (y)NDefinition of AbnormalSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation Info
Ice USA 9–13 29286 >95th   7.9 13.4 23.4   <.01   Appalachian population 
Davis USA 7–18 211 (160 for lipids) >90th   16 45   <.001   Rural Georgia 
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    13.3   <.001  OB >97th  
Puri USA 10–18 198 >95th   28    .002   General pediatrics and endocrinology patients 
Maggio Switzerland Mean 8.8 66 >95th    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    
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 = 3.8 OR = 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 = 1.0 OR = 2.50 OR = 4.31   <.05    
     Females 3.8 OR = 1.0 OR = 3.39 OR = 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       
     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, SO 120%/95th Obesity clinic patients 
     Females    32.4 46.6  <.001  OB 95th, SO 120%/95th Obesity clinic patients 
Hadjiyannakis Canada 5–17 847 >95th  14   10 26 NR   Pediatric weight management program patients 
Stolzman USA 12–17 62 >90th    13   NS   Community recruitment 

NR, not reported; NS, not significant; OB, obese; OR, odds ratio; OW, overweight; SO, severe obesity.

Reported frequencies further suggest a progressive increase in the prevalence of high SBP with increasing adiposity, although limited information is available regarding differences across classes of obesity, because only 1 study specifically focused on such categories. Studies supporting an association between elevated SBP and unhealthy weight status included samples based within the United States (n = 7) and other countries (n = 10) as well as population-based and more targeted samples. Five studies reported statistical comparisons by biological sex, all of which supported a significant relationship between elevated SBP and unhealthy weight status for both males and females. Five studies based on samples within a preteen or young-teenage range (eg, 9–13 years) supported an association between higher SBP and unhealthy weight. Prevalence comparisons were not available within studies for different age subgroups, and no studies focused specifically on young children (eg, ≤8 years).

Fifty-two studies including children ages 2 to 19 years provided mean values for SBP across different weight groups, including 21 studies from the United States (with 2 from Puerto Rico) and studies from 15 other countries, spanning 4 continents (Table 22). Within the 46 studies formally testing differences across means, 37 included a healthy weight comparison group, 32 of which reported significant increases in mean SBP with excess weight. Among studies with a healthy weight comparator, 8 specifically compared the healthy weight and overweight group or tested a trend, with 6 supporting significant increases in SBP with unhealthy weight. Seven other studies compared only groups with overweight and obesity or different classes of obesity, with 6 reporting significant increases in SBP with increasing adiposity. These findings and reported means add support to observed differences in prevalence by weight status group—that is, that SBP increases progressively with the degree of overweight or obesity. Studies reporting mean SBP also add to previous insights by providing additional comparisons within sex and age subgroups. Of the 18 studies including formal subgroup comparisons, 16 compared weight status categories within both males and females. Most reported significant differences across weight groups in the expected direction for both males and females. Only 3 studies reported comparisons for subgroups by age, and 2 of these only compared younger and older children and adolescents, although 2 studies also compared means by age for both males and females. Also, 1 study compared means for 4 age subgroups, ranging from 2 to 5 years to 16 to 19 years.102  In addition to the general observation of increased SBP with age, significant differences in SBP were reported by weight status for all comparisons, regardless of age or sex. Although few studies addressed changes in SBP for very young children, it should also be noted that 2 other studies reported similar findings for cohorts 6 years or younger.46,105  Combined prevalence and mean tables for SBP support progressive increases in SBP and the prevalence of elevated SBP with increasing adiposity. The available studies further suggest that this finding holds in males and females and is likely generalizable across age, although limited evidence is still available relevant to younger subgroups.

TABLE 22

Mean Systolic Blood Pressure (n = 52)

First AuthorCountryAges (y)NUnitsSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight definitionsPopulation Info
Avnieli Velfer Israel 2–18 1027 mm Hg Males    116 120  <.001  OB 95th, SO 120%/95th Obesity clinic patients 
     Females    116 116  .01  OB 95th, SO 120%/95th Obesity clinic patients 
Hadjiyannakis Canada 5–17 847 mm Hg  116   113 117 120 NR   Pediatric weight management program patients 
Kim Korea 12–13 120 mm Hg   100 110    <.001   School based 
Kloppenberg Denmark Median 12 3978 z-score Males  1.23 1.55 1.75   <.001 P value includes differences by sex HW: <90th, OW: 90th–99th, OB: >99th Weight management clinic + population-based 
     Females  1.25 1.24 1.75   <.001 P value includes differences by sex HW: <90th, OW: 90th–99th, OB: >99th Weight management clinic + population-based 
Sougawa Japan 12–18 1679 mm Hg Males 114.3 112.8 121.0    <.001   Schools 
     Females 105.8 104.8 113.3    <.001   Schools 
Stolzman USA 12–17 62 mm Hg   106.9  114.1   <.05   Community recruitment 
Tsao-Wu USA 2–5 154 percentile     66.9 60.1 66.8 NR   Weight management clinic patients 
  6–11 880 percentile     53.9 59.9 67.4 NR   Weight management clinic patients 
  12–17 1004 percentile     67.4 64.3 69.8 NR   Weight management clinic patients 
First AuthorCountryAges (y)NUnitsSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight definitionsPopulation Info
Avnieli Velfer Israel 2–18 1027 mm Hg Males    116 120  <.001  OB 95th, SO 120%/95th Obesity clinic patients 
     Females    116 116  .01  OB 95th, SO 120%/95th Obesity clinic patients 
Hadjiyannakis Canada 5–17 847 mm Hg  116   113 117 120 NR   Pediatric weight management program patients 
Kim Korea 12–13 120 mm Hg   100 110    <.001   School based 
Kloppenberg Denmark Median 12 3978 z-score Males  1.23 1.55 1.75   <.001 P value includes differences by sex HW: <90th, OW: 90th–99th, OB: >99th Weight management clinic + population-based 
     Females  1.25 1.24 1.75   <.001 P value includes differences by sex HW: <90th, OW: 90th–99th, OB: >99th Weight management clinic + population-based 
Sougawa Japan 12–18 1679 mm Hg Males 114.3 112.8 121.0    <.001   Schools 
     Females 105.8 104.8 113.3    <.001   Schools 
Stolzman USA 12–17 62 mm Hg   106.9  114.1   <.05   Community recruitment 
Tsao-Wu USA 2–5 154 percentile     66.9 60.1 66.8 NR   Weight management clinic patients 
  6–11 880 percentile     53.9 59.9 67.4 NR   Weight management clinic patients 
  12–17 1004 percentile     67.4 64.3 69.8 NR   Weight management clinic patients 

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

Diastolic Blood Pressure

A total of 19 studies examined the prevalence of abnormal diastolic blood pressure (DBP),5,7,8,10,13,15,18, 24,25,3539,63,97,98,100,101  whereas 51 provided mean values for DBP.5,7,8,10,13,18,22,24,32,33,35,36,39,40, 4246,4850,5456,5966,68,7175,77,79,83, 90,97,99,102,103,105108  Sixteen studies reported on the prevalence of abnormal DBP across weight groups in cohorts ranging from 3 to 19 years of age, with 7 of the studies conducted in the United States (Table 23). The majority of the studies (13 of 19) defined abnormal DBP as a DBP >95th percentile for age, height, and biological sex. Five studies defined abnormal DBP as DBP >90th percentile, and 1 study from Canada defined abnormal DBP as DBP >75th percentile. Of the studies that defined abnormal DBP as >95th percentile and compared prevalence across children with healthy weight, overweight, and obesity, the prevalence of abnormal DBP ranged from 0% to 9.4% among children with healthy weight and increased to 4% to 20% among children and adolescents with class 1 obesity. Of the studies that defined abnormal DBP as >90th percentile, prevalence of abnormal DBP for children with normal weight ranged from 4% to 9.7%, which increased to 9% to 29.4% (among males) for children with class 1 obesity. Across all studies, age ranged from 3 to 19 years, with only 2 studies examining abnormal DBP by age group.24,25  Two studies reported data from NHANES, the larger study of which (n = 8579) showed a significant increase in prevalence of abnormal DBP among children with increasing weight status (overweight and class III obesity).37,38  For studies that examined significant differences in abnormal DBP across weight categories (13 of 19), 8 showed a significantly higher prevalence of abnormal DBP among children in a higher weight category compared with children in a lower weight category. Among the largest study (n = 29 286), prevalence increased from 9.4% in children with healthy weight to 20.1% in children with class I obesity.15 

TABLE 23

Prevalence of Abnormal Diastolic Blood Pressure (n = 19)

First AuthorCountryAges (y)NDefinition of AbnormalSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPWeight DefinitionsPopulation Info
Ice USA 9–13 29286 >95th   9.4 12.8 20.1   <.01   
Davis USA 7–18 211 >90th     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 = 10.8 115 >95th     14.7  <.001 OB >97th  
Puri USA 10–18 198 >95th      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   
     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 = 1.0 OR = 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 = 1.0 OR = 2.50 OR = 5.74   <.05   
     Females 3.7 OR = 1.0 OR = 1.66 OR = 5.05   <.05   
Serap Turkey 6–16 284 >95th Males  1.9  12.4   <.001  Pediatric endocrinology patients 
     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, SO 120%/95th Obesity clinic patients 
     Females       NS OB 95th, SO 120%/95th Obesity clinic patients 
Hadjiyannakis Canada 5–17 847 >95th    10 NR  Pediatric weight management program patients 
Stolzman USA 12–17 62 >90th      NS  Community recruitment 
First AuthorCountryAges (y)NDefinition of AbnormalSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPWeight DefinitionsPopulation Info
Ice USA 9–13 29286 >95th   9.4 12.8 20.1   <.01   
Davis USA 7–18 211 >90th     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 = 10.8 115 >95th     14.7  <.001 OB >97th  
Puri USA 10–18 198 >95th      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   
     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 = 1.0 OR = 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 = 1.0 OR = 2.50 OR = 5.74   <.05   
     Females 3.7 OR = 1.0 OR = 1.66 OR = 5.05   <.05   
Serap Turkey 6–16 284 >95th Males  1.9  12.4   <.001  Pediatric endocrinology patients 
     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, SO 120%/95th Obesity clinic patients 
     Females       NS OB 95th, SO 120%/95th Obesity clinic patients 
Hadjiyannakis Canada 5–17 847 >95th    10 NR  Pediatric weight management program patients 
Stolzman USA 12–17 62 >90th      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.

A total of 51 studies examined mean DBP (Table 24); 28 of them reported significant differences in mean DBP by weight status. Notably, of the population-based studies, none reported consistently higher DBP among those with obesity. One reported higher DBP among females8  and another only in 11- to 18-year-old males.50  Studies showing a significant difference in DBP by weight status indicated a stepwise increase in DBP as weight increased from healthy weight to obesity. Only 1 school-based study included severe obesity, reporting significantly higher DBP in children with class II obesity compared with those with class I obesity.22  With the exception of some clinic samples, the mean reported DPB was <70 mm Hg, even among children with obesity.

TABLE 24

Mean Diastolic Blood Pressure (n = 51)

First AuthorCountryAges (y)NUnitsSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation Info
Avnieli Velfer Israel 2–18 1027 mm Hg Males    66.5 70  .003  OB 95th, SO 120%/95th Obesity clinic patients 
     Females    67.5 67.5  .31  OB 95th, SO 120%/95th Obesity clinic patients 
Hadjiyannakis Canada 5–17 847 mm Hg  70   69 70 72 NR   Pediatric weight management program patients 
Kim Korea 12–13 120 mm Hg   60 60    .039   School based 
Kloppenberg Denmark Median 12 3978 z-score Males  0.09 0.21 0.54   <.001 P value includes differences by sex HW: <90th, OW: 90th–99th, OB: >99th Weight management clinic + population-based 
     Females  0.40 0.5 0.78   <.001 P value includes differences by sex HW: <90th, OW: 90th–99th, OB: >99th Weight management clinic + population-based 
Sougawa Japan 12–18 1679 mm Hg Males 60.5 59.7 64.3    <.001   Schools 
     Females 60.8 60.3 65.4    <.001   Schools 
Stolzman USA 12–17 62 mm Hg   71.9  74.1   NS   Community recruitment 
Tsao-Wu USA 2–5 154      69.5 70.1 71.1 NR   Weight management clinic patients 
  6–11 880      51.3 56.1 60.9 NR   Weight management clinic patients 
  12–17 1004      55.6 56.8 62.9 NR   Weight management clinic patients 
First AuthorCountryAges (y)NUnitsSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation Info
Avnieli Velfer Israel 2–18 1027 mm Hg Males    66.5 70  .003  OB 95th, SO 120%/95th Obesity clinic patients 
     Females    67.5 67.5  .31  OB 95th, SO 120%/95th Obesity clinic patients 
Hadjiyannakis Canada 5–17 847 mm Hg  70   69 70 72 NR   Pediatric weight management program patients 
Kim Korea 12–13 120 mm Hg   60 60    .039   School based 
Kloppenberg Denmark Median 12 3978 z-score Males  0.09 0.21 0.54   <.001 P value includes differences by sex HW: <90th, OW: 90th–99th, OB: >99th Weight management clinic + population-based 
     Females  0.40 0.5 0.78   <.001 P value includes differences by sex HW: <90th, OW: 90th–99th, OB: >99th Weight management clinic + population-based 
Sougawa Japan 12–18 1679 mm Hg Males 60.5 59.7 64.3    <.001   Schools 
     Females 60.8 60.3 65.4    <.001   Schools 
Stolzman USA 12–17 62 mm Hg   71.9  74.1   NS   Community recruitment 
Tsao-Wu USA 2–5 154      69.5 70.1 71.1 NR   Weight management clinic patients 
  6–11 880      51.3 56.1 60.9 NR   Weight management clinic patients 
  12–17 1004      55.6 56.8 62.9 NR   Weight management clinic patients 

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

TABLE 25

Prevalence of Hypertension (n = 61)

First AuthorCountryAges (y)NDefinition of AbnormalSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation 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  20    <.05    
     5–8 y AA  10 28    <.05    
     9–12 y white  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       
     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 = 2.25 OR = 3.88   <.05    
     Rural 2.9 ref OR = 5.71 OR = 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      
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 = 1  aOR = 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 = 1.0 aOR = 1.87 aOR = 3.76   <.05    
Moore USA 5–17 1829 >95th Males 14.5% OR = 1.0 aOR = 2.48 aOR = 4.33   <.05    
     Females 13.0% OR = 1.0 OR = 1.69 OR = 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, 2: BMI 50–60, 3: BMI >60 Bariatric surgery patients 
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, >70–80 Males   10.7 24.9       
     Females   11.7 26.5       
Voorhees USA 11–13 426 >90th  12% 1.0 1.2 9.7   <.05 OB   Hmong + 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 diagnosed  1% OR = 1.0 OR = 1.0 OR = 3.5   <.05 OB   Patients with type 1 diabetes mellitus 
Menghetti Italy 6–17 2007 >95th  5.5 F, 6.9 M OR = 1.0  OR = 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 = 1.0 OR = 1.6 OR = 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 = 1 aOR = 4.88 aOR = 38.37   <.05    
Levin Israel 17 1 021 211 >180/110 Males  0.03  0.26   <.001 Severe hypertension  Reporting for military 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 = 1.0 aOR = 1.50 aOR = 1.94   Both <.05    
Chiolero Switzerland 6th grade 5207 >95th  11.4% OR = 1.0 OR = 2.7 OR = 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 31  62     Clinic patients 
Gunes USA 11–18 363 >95th percentile Males   10.7 24.6   .111   Adolescent clinic patients 
     Females   20.6 29.5   .198   Adolescent clinic patients 
Hadjiyannakis Canada 5–17 847 >95th SBP or DBP    NR   Pediatric weight 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 + some community 
Rodrigues Portugal 6–9 1555 >95th percentile Males 3.1 1.0 (ref) aOR = 1.26, P = .69 aOR = 3.40, P = .08      Schools 
    >95th percentile Females 4.3 1.0(ref) aOR = 2.43, P = .03 aOR = 5.26, P < .01      Schools 
    “High-normal,” 90th-95th Males 3.4 1.0 aOR = 2.34, P = .09 aOR = 6.13, P < .01    Hypertension in separate submission  Schools 
    “High–normal,” 90th–95th Females 5.6 1.0(ref) aOR = 1.28, P = .53 aOR = 4.25, P < .01      Schools 
Silverio USA 2–17 421 ICD-10   0.93  5.7   .006   Family medicine clinic patients 
Tsao-Wu USA 2–5 154 >95th percentile     NR   Weight management clinic patients 
  6–11 880      1.6 3.4 NR   Weight management clinic patients 
  12–17 1004      1.6 2.2 7.7 NR   Weight management clinic patients 
First AuthorCountryAges (y)NDefinition of AbnormalSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation 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  20    <.05    
     5–8 y AA  10 28    <.05    
     9–12 y white  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       
     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 = 2.25 OR = 3.88   <.05    
     Rural 2.9 ref OR = 5.71 OR = 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      
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 = 1  aOR = 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 = 1.0 aOR = 1.87 aOR = 3.76   <.05    
Moore USA 5–17 1829 >95th Males 14.5% OR = 1.0 aOR = 2.48 aOR = 4.33   <.05    
     Females 13.0% OR = 1.0 OR = 1.69 OR = 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, 2: BMI 50–60, 3: BMI >60 Bariatric surgery patients 
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, >70–80 Males   10.7 24.9       
     Females   11.7 26.5       
Voorhees USA 11–13 426 >90th  12% 1.0 1.2 9.7   <.05 OB   Hmong + 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 diagnosed  1% OR = 1.0 OR = 1.0 OR = 3.5   <.05 OB   Patients with type 1 diabetes mellitus 
Menghetti Italy 6–17 2007 >95th  5.5 F, 6.9 M OR = 1.0  OR = 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 = 1.0 OR = 1.6 OR = 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 = 1 aOR = 4.88 aOR = 38.37   <.05    
Levin Israel 17 1 021 211 >180/110 Males  0.03  0.26   <.001 Severe hypertension  Reporting for military 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 = 1.0 aOR = 1.50 aOR = 1.94   Both <.05    
Chiolero Switzerland 6th grade 5207 >95th  11.4% OR = 1.0 OR = 2.7 OR = 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 31  62     Clinic patients 
Gunes USA 11–18 363 >95th percentile Males   10.7 24.6   .111   Adolescent clinic patients 
     Females   20.6 29.5   .198   Adolescent clinic patients 
Hadjiyannakis Canada 5–17 847 >95th SBP or DBP    NR   Pediatric weight 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 + some community 
Rodrigues Portugal 6–9 1555 >95th percentile Males 3.1 1.0 (ref) aOR = 1.26, P = .69 aOR = 3.40, P = .08      Schools 
    >95th percentile Females 4.3 1.0(ref) aOR = 2.43, P = .03 aOR = 5.26, P < .01      Schools 
    “High-normal,” 90th-95th Males 3.4 1.0 aOR = 2.34, P = .09 aOR = 6.13, P < .01    Hypertension in separate submission  Schools 
    “High–normal,” 90th–95th Females 5.6 1.0(ref) aOR = 1.28, P = .53 aOR = 4.25, P < .01      Schools 
Silverio USA 2–17 421 ICD-10   0.93  5.7   .006   Family medicine clinic patients 
Tsao-Wu USA 2–5 154 >95th percentile     NR   Weight management clinic patients 
  6–11 880      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.

Hypertension

An additional 61 studies examined the prevalence of hypertension (Table 25).6,7,9,1114,16,17,2023,26, 2933,37,40,42,77,78,8083,92,102,108137  All studies reported on the prevalence across weight groups, with the majority of studies comparing hypertension prevalence between children of healthy weight and those with obesity. Fifteen studies reported on prevalence of hypertension among children and teenagers with increasing obesity severity (class I to class III), whereas 4 studies examined prevalence of hypertension among children with healthy weight and overweight. All studies except 133  that examined the association between hypertension and weight group showed significant differences in the prevalence of hypertension between weight categories, with increasing prevalence of hypertension with increasing weight category. The studies were conducted in various countries; 34 reported US data. The majority of the studies (n = 37) defined hypertension as SBP or DBP >95th percentile for age, biological sex, and height. Of these studies, hypertension prevalence for children of healthy weight across age groups ranged from 1% to 14% compared with 4% to 30% for children with obesity. As expected, prevalence was lowest in early childhood (4% to 6% for children with healthy weight and 8% for children with obesity) and highest among teenagers (2% to 10% for teenagers with healthy weight and 3% to 39% among teenagers with obesity). Studies that defined hypertension as SBP or DBP >90th percentile for age, sex, and height (n = 13) showed similar prevalence both for children with healthy weight (5% to 12%) and those with obesity (18% to 24%) across all age groups. For studies (n = 2) with the large population samples (n > 20 000) of children ages 6 to 19 years and the most rigorous definition of hypertension (SBP or DBP >95th percentile on 3 repeated measures), hypertension prevalence was ∼1% for children with healthy weight and ∼5% for children with obesity, increasing to 9% for children with class II obesity.

Alanine Aminotransferase

A total of 8 studies examined the prevalence of abnormal alanine aminotransferase (ALT),6,34,67,81,83,104,138,139  and 8 provided mean values for ALT.6,13,53,54,66,67,70,74  Three additional studies examined the prevalence of nonalcoholic fatty liver disease (NAFLD).5,67,70  The 8 studies examining the prevalence of abnormal ALT (Table 26) used a range of definitions from >20 U/L to >40 U/L and each of the 5 studies used a different cut point. Four studies found significant differences in prevalence of abnormal ALT between children with healthy weight and children with obesity.6,67,104,139  Two studies included only children with obesity; 1 found no significant difference between class I, II, or III obesity in prevalence of abnormal ALT,34  whereas another did.81  Two additional studies did not provide statistical analysis of prevalence.83,138 

TABLE 26

Prevalence of Abnormal ALT (n = 8)

First AuthorCountryAges (y)NSubgroup (eg, M/F)Definition of AbnormalTotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation Info
Kopping USA Mean 9.6 226 No >90th 14.9 OR = 1.0  OR = 2.51   .009    
Bell Australia 6–13 283 No >30 U/L  3.8 9.0 31.6   <.001    
Salvatore USA 3–18 101 No >36    16.7 41.4 38.2 .082    
Purcell Mexico 8–19 1262 Yes >40 U/L  3.9 22.9 38.1   <.001    
Booth Australia 14–17 496 Males >32 U/L 9.0 2.9 19.7 42.1       
    Females >20 U/L 5.3 3.0 19.4 0.0       
Lennerz Germany 14–24 431  >50 U/L    15 26 30 .002   Weight management clinic patients + some community 
Seth USA Mean 13 767  >80 U/L   13 25 31 36 .002   Steatohepatitis clinic patients 
Tsao-Wu USA 2–5 154  >22 U/L females; <26 U/L males    6.9 6.4 6.4 NR   Weight management clinic patients 
  6–11 880      6.6 7.0 10.5 NR   Weight management clinic patients 
  12–17 1004      6.4 7.1 9.0 NR   Weight management clinic patients 
First AuthorCountryAges (y)NSubgroup (eg, M/F)Definition of AbnormalTotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation Info
Kopping USA Mean 9.6 226 No >90th 14.9 OR = 1.0  OR = 2.51   .009    
Bell Australia 6–13 283 No >30 U/L  3.8 9.0 31.6   <.001    
Salvatore USA 3–18 101 No >36    16.7 41.4 38.2 .082    
Purcell Mexico 8–19 1262 Yes >40 U/L  3.9 22.9 38.1   <.001    
Booth Australia 14–17 496 Males >32 U/L 9.0 2.9 19.7 42.1       
    Females >20 U/L 5.3 3.0 19.4 0.0       
Lennerz Germany 14–24 431  >50 U/L    15 26 30 .002   Weight management clinic patients + some community 
Seth USA Mean 13 767  >80 U/L   13 25 31 36 .002   Steatohepatitis clinic patients 
Tsao-Wu USA 2–5 154  >22 U/L females; <26 U/L males    6.9 6.4 6.4 NR   Weight management clinic patients 
  6–11 880      6.6 7.0 10.5 NR   Weight management clinic patients 
  12–17 1004      6.4 7.1 9.0 NR   Weight management clinic patients 

NR, not reported; OR, odds ratio.

Four studies provided mean values for ALT (Table 27). Three studies compared mean ALT between children with healthy weight and children with overweight and obesity and found a significant difference in mean ALT between groups.6,53,54  A study of children with Down syndrome found no difference between mean ALT in children with healthy weight and children who were overweight.70  Four studies compared mean ALT in children with overweight and class I, II, III obesity, and 3 found significant differences in mean ALT between children with overweight and children with obesity.66,67,74 

TABLE 27

Mean ALT (n = 8)

First AuthorCountryAges (y)NUnitsSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight definitionsPopulation Info
Bell Australia 6–13 283 UI/L   15.94 21.15 24.90   <.002    
Zabarsky USA 7–20 2244 U/L    17 24 25 29 <.001 IV = 26   
Valentini Italy 5–18 84 UI/L   27.57 28.74    NS   Patients with Down syndrome 
Salawi Canada 6–19 345 U/L    24.9   31.6 .001    
Hadjiyannakis Canada 5–17 847 IU/L  25.0   21.0 25.5 30.5 NR   Pediatric weight management program patients 
Higgins Canada 5–19 1332 U/L Males  17 189 23   <.05  OW = 85th–97th %ile, OB > 97th Community 
     Females  16 16 17   NS  OW = 85th–97th %ile, OB > 97th Community 
Kim Korea 12–13 120 IU/L   11 19    <.001   School based 
Seth US Mean 13 767 U/L    41 59 61 64 .001   Steatohepatitis clinic patients 
First AuthorCountryAges (y)NUnitsSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight definitionsPopulation Info
Bell Australia 6–13 283 UI/L   15.94 21.15 24.90   <.002    
Zabarsky USA 7–20 2244 U/L    17 24 25 29 <.001 IV = 26   
Valentini Italy 5–18 84 UI/L   27.57 28.74    NS   Patients with Down syndrome 
Salawi Canada 6–19 345 U/L    24.9   31.6 .001    
Hadjiyannakis Canada 5–17 847 IU/L  25.0   21.0 25.5 30.5 NR   Pediatric weight management program patients 
Higgins Canada 5–19 1332 U/L Males  17 189 23   <.05  OW = 85th–97th %ile, OB > 97th Community 
     Females  16 16 17   NS  OW = 85th–97th %ile, OB > 97th Community 
Kim Korea 12–13 120 IU/L   11 19    <.001   School based 
Seth US Mean 13 767 U/L    41 59 61 64 .001   Steatohepatitis clinic patients 

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

Aspartate Aminotransferase and NAFLD

A total of 2 studies examined the prevalence of abnormal aspartate aminotransferase (AST),34,138  whereas 4 provided mean values for AST.53,54,67,70  Of the 2 studies examining the prevalence of abnormal AST (Table 28), 1 from a pediatric endocrine clinic found no significant difference abnormal AST among children with class I, II, or III obesity.34  The other study did not provide statistical analysis of prevalence.138  A study of children with Down syndrome showed a significant 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 study showed almost double the prevalence of NAFLD (Table 30) in children who were overweight. Another study showed no significant differences by obesity severity for mean AST or NAFLD.67  A third study demonstrated greater prevalence of NAFLD among those with severe obesity, compared with class I obesity.5 

TABLE 28

Prevalence of Abnormal AST (n = 2)

First AuthorCountryAges (y)NSubgroup (eg, M/F)Definition of AbnormalTotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation Info
Salvatore US 3–18 101  >46   13.3 31.0 11.8 .099   Pediatric endocrinology patients 
Booth Australia 14–17 496 Males >33 U/L 7.2 4.3 11.5 26.3       
    Females >26 U/L 4.9 4.2 9.7 0.0       
First AuthorCountryAges (y)NSubgroup (eg, M/F)Definition of AbnormalTotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation Info
Salvatore US 3–18 101  >46   13.3 31.0 11.8 .099   Pediatric endocrinology patients 
Booth Australia 14–17 496 Males >33 U/L 7.2 4.3 11.5 26.3       
    Females >26 U/L 4.9 4.2 9.7 0.0       
TABLE 29

Mean AST (n = 4)

First AuthorCountryAges (y)NUnitsSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight definitionsPopulation Info
Valentini Italy 5–18 84 UI/L No  35.00 30.12    0.03   Patients with Down syndrome 
Higgins Canada 5–19 1332 U/L Males  26 24 25   NS  OW = 85th–97th %ile, OB > 97th Community 
     Females  23 23 23   NS  OW = 85th–97th %ile, OB > 97th Community 
Kim Korea 12–13 120 IU/L   18 20.5    0.004   School based 
Seth USA Mean 13 767 U/L    29 35 35 37 0.16   Steatohepatitis clinic patients 
First AuthorCountryAges (y)NUnitsSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight definitionsPopulation Info
Valentini Italy 5–18 84 UI/L No  35.00 30.12    0.03   Patients with Down syndrome 
Higgins Canada 5–19 1332 U/L Males  26 24 25   NS  OW = 85th–97th %ile, OB > 97th Community 
     Females  23 23 23   NS  OW = 85th–97th %ile, OB > 97th Community 
Kim Korea 12–13 120 IU/L   18 20.5    0.004   School based 
Seth USA Mean 13 767 U/L    29 35 35 37 0.16   Steatohepatitis clinic patients 

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

TABLE 30

Prevalence of NAFLD (n = 3)

First AuthorCountryAges (y)NSubgroup (eg, M/F)Definition of AbnormalTotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation Info
Valentini Italy 5–18 84 No Diagnosis 64.3 45 82       Patients with Down syndrome 
Seth US Mean 13 767  Stiffness >2.71 kPa   20 22 27 30 .13   Steatohepatitis clinic patients 
Avnieli Velfer Israel 2–18 1027 Males Sonographic evidence of fatty infiltration    4.1 19.7  <.001  OB 95th, SO 120%/95th Obesity clinic patients 
    Females     4.9 18.6  <.001  OB 95th, SO 120%/95th Obesity clinic patients 
First AuthorCountryAges (y)NSubgroup (eg, M/F)Definition of AbnormalTotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation Info
Valentini Italy 5–18 84 No Diagnosis 64.3 45 82       Patients with Down syndrome 
Seth US Mean 13 767  Stiffness >2.71 kPa   20 22 27 30 .13   Steatohepatitis clinic patients 
Avnieli Velfer Israel 2–18 1027 Males Sonographic evidence of fatty infiltration    4.1 19.7  <.001  OB 95th, SO 120%/95th Obesity clinic patients 
    Females     4.9 18.6  <.001  OB 95th, SO 120%/95th Obesity clinic patients 

OB, obese; SO, severe obesity.

Eight studies examined the prevalence of obstructive sleep apnea (OSA) (Table 31).5,6,13,83,135,140  By parent report, there was no significant difference in the prevalence of OSA among children with healthy weight, overweight, or obesity.6  Studies using polysomnography results show increasing prevalence of OSA as obesity severity increases.5,83,140,141  Studies using diagnosis of OSA also find increased OSA as obesity worsens.135,142 

TABLE 31

Prevalence of obstructive sleep apnea (n = 8)

First AuthorCountryAges (y)NSubgroup (eg, M/F)Definition of AbnormalTotalHealthyOverweightClass IClass IIClass IIIPNotesWeight definitionsPopulation Info
Andersen Denmark 7–18 172  Apnea–Hypopnea Index ≥2  9.1 44.6    .0002  Overweight 90th, obesity 99th Clinic patients 
Avnieli Velfer Israel 2–18 1027 Males AHI >1    41 17.3  <.001  OB 95th, SO 120%/95th Obesity clinic patients 
    Females     1.3 13.9  <.001  OB 95th, SO 120%/95th Obesity clinic patients 
Frye US 5–12 421  Persistent SDB over 8 y  1.0 (ref) aOR = 2.00 aOR = 2.75   OW = .101, OB <.001   Population-based 
Hadjiyannakis Canada 5–17 847  Chart review   17 NR   Pediatric weight management program patients 
Kelly UK 5–8 9443  Diagnosis (3 y following BMI)  1.0 (ref)  aOR = 2.50   <.05   Population based 
Silverio US 2–17 421  ICD-10  0.46  2.8   .05   Family medicine clinic patients 
Tsao-Wu US 2–5 154  AHI >1    3.4 8.5 12.8 NR   Weight management clinic patients 
  6–11 880      1.7 5.4 11.4 NR   Weight management clinic patients 
  12–17 1004      4.4 4.4 13.6 NR   Weight management clinic patients 
First AuthorCountryAges (y)NSubgroup (eg, M/F)Definition of AbnormalTotalHealthyOverweightClass IClass IIClass IIIPNotesWeight definitionsPopulation Info
Andersen Denmark 7–18 172  Apnea–Hypopnea Index ≥2  9.1 44.6    .0002  Overweight 90th, obesity 99th Clinic patients 
Avnieli Velfer Israel 2–18 1027 Males AHI >1    41 17.3  <.001  OB 95th, SO 120%/95th Obesity clinic patients 
    Females     1.3 13.9  <.001  OB 95th, SO 120%/95th Obesity clinic patients 
Frye US 5–12 421  Persistent SDB over 8 y  1.0 (ref) aOR = 2.00 aOR = 2.75   OW = .101, OB <.001   Population-based 
Hadjiyannakis Canada 5–17 847  Chart review   17 NR   Pediatric weight management program patients 
Kelly UK 5–8 9443  Diagnosis (3 y following BMI)  1.0 (ref)  aOR = 2.50   <.05   Population based 
Silverio US 2–17 421  ICD-10  0.46  2.8   .05   Family medicine clinic patients 
Tsao-Wu US 2–5 154  AHI >1    3.4 8.5 12.8 NR   Weight management clinic patients 
  6–11 880      1.7 5.4 11.4 NR   Weight management clinic patients 
  12–17 1004      4.4 4.4 13.6 NR   Weight management clinic patients 

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

A total of 26 studies reported the prevalence of asthma (Table 32).135,142166  Virtually all studies used parent-reported or self-reported asthma, although they varied in the reporting of current asthma or ever having asthma, as well as specifically asking for report of a physician diagnosis. Most studies showed significantly higher asthma in children with obesity compared with children healthy weight. One nationally representative US study of children 2 to 19 years of age showed 15.7% children with obesity had asthma, compared with 10.3% of children with healthy weight.144  Only 2 studies, both of a health plan population, included children with severe obesity, demonstrating a stepwise increase in asthma incidence and prevalence as weight status increased.148,149 

TABLE 32

Prevalence of Asthma (n = 26)

First AuthorCountryAges (y)NDefinition of AbnormalSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation Info
Guibas Greece 2–5, 9–13 1622 Physician diagnosis 2–5 y 10.5 1.0 OR = 1.29 OR = 1.54   NS    
   2015 Physician diagnosis 9–13 y 13.5 OR = 1.0 OR = 1.45 OR = 1.69   <.05    
Gilliland US 7–18 3792 Physician diagnosis Males  IR = 20.0/1000 IR = 25.2/1000 IR = 36.6/1000       
    Physician diagnosis Females  25.2/1000 34.5/1000 25.6/1000       
Black US 6–19 623358 Incident physician diagnosis  IR 18.1/1000 aHR = 1.16 aHR = 1.23 aHR = 1.37  <.001   Kaiser 
Bibi Israel 2nd grade 5984 Parent report of physician diagnosis Males   14.6   <.001    
     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 asthma  9.5% 7.1 12.1 11.6   <.05   Northern Plains American Indian patients 
Sybilski Poland 6–7, 13–14 4510 Physician diagnosis 6–7 y 11.44 1.00 (ref) OR = 1.99 OR = 2.17   <.05    
   4721  13–14 y 11.36 1.00 (ref) OR = 1.43 OR = 0.57   NS    
Lu US 12–19 4828 Parent report current asthma Males 6.5% aOR = 1.0 aOR = 0.90    NS   NHANES sample 
     Females 8.5% aOR = 1.0 aOR = 1.73    <.05    
James Australia 4–6 18999 Parent report current asthma  13.11% OR = 1.0 1.29 1.29   <.05    
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, 13–14 3360 Parent report ever asthma 6–7 y 9.8 OR = 1.0 OR = 1.14 OR = 2.29   <.05 OB    
   5247  13–14 y 10.4 OR = 1.0 OR = 1.14 OR = 1.18   NS    
Akinbami US 2–19 9437 Parent report current asthma NHANES 1998–1994 7.3 6.3 8.4 13.4   .03   1988–1994 
   6112  NHANES 2011–2014 10.9 10.3 8.2 15.7   .001   2011–2014 sample 
Tai Australia 4–5 1509 Parent report current asthma Males  19.2 29.9 37.1   .005    
     Females  15.3 15.2 37.5   <.001    
Yoo Korea 15–17 717 Parent report current asthma Males  6.9% 9.5%    .285    
     Females  3.7% 3.6%    .973    
Kwon US 2–11 853 Parent-report asthma diagnosis plus self-report Males  19.1 24.3 34.8   .014   Black and Hispanic patients 
     Females  16.4 33.3 27.3   .005    
Musaad US 5–18 1123 Moderate or severe physician diagnosis   38.17 40.69    NS  HW: 25th–85th  
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 (across years) 1.0 1.2 1.7      NHANES 1988-2014 
Karachaliou Greece   Parent report of any asthma symptoms   29.7 33.2    <.001   Schools 
Kelly UK 5–8 9443 Diagnosis (3 y following BMI)   1.0 (ref)  aOR = 1.46   <.05   Population based 
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 history Males  1.0 (ref)  aOR = 1.61   <.001   Military conscripts 
     Females  1.0 (ref)  aOR = 1.54   <.05   Military conscripts 
Machluf Israel 16–19 113671 Moderate-severe asthma from medical history Males  1.0 (ref)  aOR = 1.63   <.001   Military conscripts 
     Females  1.0 (ref) aOR = 1.21 aOR = 1.54   <.05   Military conscripts 
Silverio US 2–17 421 ICD-10   26.7  27.8   .79   Family medicine clinic patients 
First AuthorCountryAges (y)NDefinition of AbnormalSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation Info
Guibas Greece 2–5, 9–13 1622 Physician diagnosis 2–5 y 10.5 1.0 OR = 1.29 OR = 1.54   NS    
   2015 Physician diagnosis 9–13 y 13.5 OR = 1.0 OR = 1.45 OR = 1.69   <.05    
Gilliland US 7–18 3792 Physician diagnosis Males  IR = 20.0/1000 IR = 25.2/1000 IR = 36.6/1000       
    Physician diagnosis Females  25.2/1000 34.5/1000 25.6/1000       
Black US 6–19 623358 Incident physician diagnosis  IR 18.1/1000 aHR = 1.16 aHR = 1.23 aHR = 1.37  <.001   Kaiser 
Bibi Israel 2nd grade 5984 Parent report of physician diagnosis Males   14.6   <.001    
     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 asthma  9.5% 7.1 12.1 11.6   <.05   Northern Plains American Indian patients 
Sybilski Poland 6–7, 13–14 4510 Physician diagnosis 6–7 y 11.44 1.00 (ref) OR = 1.99 OR = 2.17   <.05    
   4721  13–14 y 11.36 1.00 (ref) OR = 1.43 OR = 0.57   NS    
Lu US 12–19 4828 Parent report current asthma Males 6.5% aOR = 1.0 aOR = 0.90    NS   NHANES sample 
     Females 8.5% aOR = 1.0 aOR = 1.73    <.05    
James Australia 4–6 18999 Parent report current asthma  13.11% OR = 1.0 1.29 1.29   <.05    
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, 13–14 3360 Parent report ever asthma 6–7 y 9.8 OR = 1.0 OR = 1.14 OR = 2.29   <.05 OB    
   5247  13–14 y 10.4 OR = 1.0 OR = 1.14 OR = 1.18   NS    
Akinbami US 2–19 9437 Parent report current asthma NHANES 1998–1994 7.3 6.3 8.4 13.4   .03   1988–1994 
   6112  NHANES 2011–2014 10.9 10.3 8.2 15.7   .001   2011–2014 sample 
Tai Australia 4–5 1509 Parent report current asthma Males  19.2 29.9 37.1   .005    
     Females  15.3 15.2 37.5   <.001    
Yoo Korea 15–17 717 Parent report current asthma Males  6.9% 9.5%    .285    
     Females  3.7% 3.6%    .973    
Kwon US 2–11 853 Parent-report asthma diagnosis plus self-report Males  19.1 24.3 34.8   .014   Black and Hispanic patients 
     Females  16.4 33.3 27.3   .005    
Musaad US 5–18 1123 Moderate or severe physician diagnosis   38.17 40.69    NS  HW: 25th–85th  
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 (across years) 1.0 1.2 1.7      NHANES 1988-2014 
Karachaliou Greece   Parent report of any asthma symptoms   29.7 33.2    <.001   Schools 
Kelly UK 5–8 9443 Diagnosis (3 y following BMI)   1.0 (ref)  aOR = 1.46   <.05   Population based 
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 history Males  1.0 (ref)  aOR = 1.61   <.001   Military conscripts 
     Females  1.0 (ref)  aOR = 1.54   <.05   Military conscripts 
Machluf Israel 16–19 113671 Moderate-severe asthma from medical history Males  1.0 (ref)  aOR = 1.63   <.001   Military conscripts 
     Females  1.0 (ref) aOR = 1.21 aOR = 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.

A total of 6 studies examined the prevalence of depression,6,13,81,135, 167,168  whereas 3 provided mean values for depression inventories.167,169,170  The studies of the prevalence of depression (Table 33) showed conflicting findings. Three, based on Center for Epidemiologic Studies Depression Scale (CES-D) scores, self-report, and International Classification of Diseases, 10th Revision (ICD-10), codes showed no difference by weight status.81,135,167  Two others, using parent report and depression inventory, showed significantly higher depression as weight status increased.6,168  The mean values for depression inventories (Table 34) were more consistent; 2 demonstrated significantly higher scores at higher weight status,169,170  whereas another smaller study examining class III obesity did not.167 

TABLE 33

Prevalence of Depression (n = 6)

First AuthorCountryAges (y)NSubgroup (eg, M/F)Definition of AbnormalTotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation Info
Goodman USA Grade 7–12 102  High CESD 9.8 9.8    9.8 1.00    
Bell Australia 6–13 283  Parent report NR 1.0 8.95 18.8   .001    
Hadjiyannakis Canada 5–17 847  Chart review 10   13 12 NR   Pediatric weight management program patients 
Lennerz Germany 14–24 431  Self-reported    11 10 11 .99   Weight management clinic patients + some community 
Silverio USA 2–17 421  ICD-10  2.3  2.4   .97   Family medicine clinic patients 
Tas Turkey 12–18 165  BSI Depression  23.6 42.7    .026   Primary care patients 
First AuthorCountryAges (y)NSubgroup (eg, M/F)Definition of AbnormalTotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation Info
Goodman USA Grade 7–12 102  High CESD 9.8 9.8    9.8 1.00    
Bell Australia 6–13 283  Parent report NR 1.0 8.95 18.8   .001    
Hadjiyannakis Canada 5–17 847  Chart review 10   13 12 NR   Pediatric weight management program patients 
Lennerz Germany 14–24 431  Self-reported    11 10 11 .99   Weight management clinic patients + some community 
Silverio USA 2–17 421  ICD-10  2.3  2.4   .97   Family medicine clinic patients 
Tas Turkey 12–18 165  BSI Depression  23.6 42.7    .026   Primary care patients 

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

TABLE 34

Mean Depression Score (n = 3)

First AuthorCountryAges (y)NUnitsSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation Info
Goodman USA Grade 7–12 102 CESD   11.9    14.0 .10    
Hammerton UK 11–17 4845 DAWBA   0.55 0.65 0.73   .007   Adolescents at risk for depression 
Goldfield Canada Grade 7–12 1490 CDI   10.2 10.3 12.1   <.05    
First AuthorCountryAges (y)NUnitsSubgroup (eg, M/F)TotalHealthyOverweightClass IClass IIClass IIIPNotesWeight DefinitionsPopulation Info
Goodman USA Grade 7–12 102 CESD   11.9    14.0 .10    
Hammerton UK 11–17 4845 DAWBA   0.55 0.65 0.73   .007   Adolescents at risk for depression 
Goldfield Canada Grade 7–12 1490 CDI   10.2 10.3 12.1   <.05    

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

Overall, across most laboratory values, diagnoses, and age groups, obesity was associated with increased prevalence of abnormal values and/or greater comorbidity prevalence. In addition, more severe degrees of obesity were associated with greater abnormalities, in concordance with prior evidence.38  However, population-based data showed smaller differences, compared with samples drawn from clinical care. Additionally, these population-based samples typically showed that the great majority of children have normal values, even children with obesity, although abnormal values were more frequently observed in the higher age categories.

In general, prevalence of abnormal lipid values varied with weight classification. For HDL cholesterol, values decreased as weight classification increased, with prevalence of abnormal HDL approximately 10% in children with healthy weight and 40% for children with obesity. There were not enough data to determine whether prevalence of abnormal HDL varied within the obesity classification by severity. Mean HDL values also showed a decrease (worsening) with increasing weight classification. Similarly, the prevalence of abnormal LDL cholesterol also increased with increasing weight classification.

The prevalence of abnormal TG increased with increasing weight classification, with the magnitude differing depending on the abnormal cutoff value chosen. Mean TG also increased as weight classification increased.

Abnormal total cholesterol values were more common in children with obesity than in children with healthy weight. There was also a significant difference in mean total cholesterol between children with healthy weight and children with obesity. In these studies, a variety of cutoffs for abnormal lipid values were used, but although prevalence varied with the cutoffs, having obesity was in all studies associated with a higher prevalence of abnormal lipid levels.

Choosing the cutoff point considered to be clinically relevant is important to understanding the potential application of these data. For example, for the studies reporting TG abnormalities, many studies selected >110 mg/dL, whereas others selected >130 mg/dL or >150 mg/dL. The prevalence varies considerably depending on the cut-point selected. Multiple organizations, including the National Lipid Association and the Endocrine Society, indicate ≥150 mg/dL as elevated TG, and other organizations, such as the American Academy of Pediatrics and the American Heart Association, indicate that the value depends on age. High TG is considered to be >100 mg/dL for children younger than 10 years and >130 mg/dL for children 10 years and older. This cutoff is important to understand patterns of high TG in children, especially when the study samples included both younger and older children. An example of the effect of the cutoff value used on prevalence differences can be seen by 2 studies conducted by Ice et al. When conducting their study with a large sample of children ages 9 to 13 years and using the cutoff of >110 mg/dL, the prevalence of high TG was 14.2% (healthy weight), 29.8% (overweight), and 49.1% (obese). However, in their other study with a large sample size of children with a mean age of 10.8 and the cut-point of >150 mg/dL, the prevalence of abnormal TG was 4.4% (healthy weight), 12.4% (overweight), and 25% (obese). There were not enough data to determine whether the prevalence of abnormal values varied within the classification of obesity.

Most of the studies that reported prevalence or mean values related to glucose metabolism observed that children and adolescents with obesity had a multifold higher prevalence of abnormal glucose, insulin, and other glucose-related values compared with children of healthy weight. These differences by weight status were reported in preschool-aged children up to adolescents. However, there was limited information on the extent to which glucose and related measures varied across categories of obesity. A few studies noted a dose-response relationship between increasing obesity classification and fasting insulin level, but many studies only compared children with healthy weight versus children with obesity, so it is less clear when glucose metabolism aberrations occur or worsen across specific severities of obesity.

There was a wide range of prevalence of abnormal HbA1c (1% to 17%), abnormal glucose (0% to 26%), abnormal insulin (0% to 80%), elevated HOMA-IR (0% to 71%), and metabolic syndrome (0% to 41%), depending on the weight status and age range of the sample and the definition used to classify abnormal values. Surprisingly, there were few studies reporting prevalence of prediabetes (1 study) or overt diabetes mellitus (6 studies) in this age range. There was great variability of mean glucose-related values within samples. However, for the most part, the reported subgroups did not have a majority of participants classified as abnormal, nor did the subgroups have a mean glucose or glucose-related value outside of the healthy range. An exception is a sample of Canadian youth ages 9 to 16 years with obesity that had an 80% prevalence of abnormal insulin, and 71% of adolescents with class III obesity entering a bariatric surgery program had abnormal HOMA-IR.26  The samples with higher prevalence and higher abnormal values were typically clinic-based, including from subspecialist clinics and/or weight management specialty clinics, including a bariatric surgery program. Among these more advanced cases of obesity, elevated insulin level was consistently high and was not differentiated by class of obesity.

There were no consistent sex differences in glucose-related measures. In general, glucose abnormalities increased in prevalence with increasing age, although there were noticeable elevations by obesity status in samples as young as preschool-aged children. There was a dearth of prevalence data available on nationally representative datasets, particularly for HOMA-IR. The presence of glucose abnormalities among youth with obesity supports the need for screening, but given the wide variability observed across population and clinic-based studies, taking into account other risk factors may be important to avoid unnecessary tests.

The prevalence of elevated SBP was higher in children with overweight and obesity compared with children with healthy weight. This association was true in both males and females. Mean values of SBP were significantly different between children with healthy weight and children with overweight and obesity. Within the obesity classification, mean SBP increased with increasing BMI. The association between SBP and BMI was observed in all age groups study and in both males and females. DBP prevalence also varied with BMI across age groups and increased within increasing obesity classifications. Hypertension (defined as elevated SBP or DBP) prevalence increased with increasing BMI. Prevalence also increased with age.

The association of increased prevalence of SBP, DBP, and hypertension in children in children with overweight and obesity in addition to increased mean SBP and DBP supports BP screening these groups.

There are a limited number of studies examining prevalence of abnormal AST and ALT. Increases in prevalence were found between children with healthy weight and children with obesity. Two studies examined prevalence within obesity classifications and found no difference in prevalence. Differences in mean ALT were found between children with normal weight and those with obesity in addition to increases in mean ALT with increasing obesity classification.

One study of mean AST did not find any difference within obesity classification. Only 1 study documented prevalence of NAFLD, pointing to an important area of future research, particularly because this study observed a doubled prevalence of NAFLD in children with overweight compared with children with normal weight. Further, only 1 study reported prevalence of OSA. With so few data, it is difficult to make screening recommendations.

Asthma is consistently associated with obesity in children at a variety of ages. In contrast to the previously discussed comorbidities, however, asthma presents symptomatically.

Therefore, it is unclear whether the data demonstrate a need for increased asthma screening.

Data regarding the relationship between obesity and depression are particularly limited.

These data suggest there may be a relationship between obesity depression but are not adequate to make statements regarding the need for screening, specifically for children with obesity. All children 12 years and older should be screened for depression, regardless of weight status.171 

There are several limitations of the current literature that warrant attention. First, the cross-sectional design of these studies prevented an examination of within-individual changes in comorbidity prevalence as it relates to fat accumulation and obesity and comorbidity incidence across the age range. This limitation makes it difficult for a primary care provider to determine when during a young patient’s life these screenings are most efficient, useful, and necessary. Many studies examined samples with wide age ranges and did not stratify by age group, making it difficult to identify a window of opportunity when screening may be most useful for early detection of a patient’s transition into pathophysiology. Further, although there were distinct differences in prevalence of abnormalities and mean laboratory values between children with normal weight versus those who were overweight and obese, more information is needed on the specific amount of body fat or level of BMI at which aberrations occur. Although screening youth with severe obesity may be commonly practiced, we currently have too few data to determine whether youth in the overweight range or at the low end of obesity should be screened.

The inconsistency in definitions of comorbidities is also challenging in this age range. It is difficult to compare prevalence estimates when studies use different thresholds for a clinically abnormal or pathologic level. Further, it is challenging for the primary care provider to develop treatment strategies without more concrete guidelines on how to interpret screening results. The inconsistency in definitions made it difficult to compare prevalence across countries, across race and ethnic groups, and across a variety of settings. There are insufficient data on national prevalence estimates, with many studies using convenience samples via school-based screening or specialty clinical settings. Less is known about the occurrence of obesity comorbidities in primary care settings as detected by providers. The utilization of large electronic medical record databases may be an efficient remedy to this lack of data.

Overall, across most laboratory values and diagnoses, obesity was associated with higher mean values and/or greater comorbidity prevalence. However, population-based data showed smaller differences, compared with samples drawn from clinical care. Additionally, these population-based samples typically showed that the great majority of children have normal values, even children with obesity.

We thank Chelsea Kracht, PhD, for her help in reviewing abstracts.

Technical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, technical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or 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, 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.

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.

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

ALT

alanine aminotransferase

AST

aspartate aminotransferase

ATP

Adult Treatment Panel

CDC

Centers for Disease Control and Prevention

DBP

diastolic blood pressure

HbA1c

hemoglobin A1c

HDL

high-density lipoprotein

HOMA-IR

homeostatic model assessment for insulin resistance

IDF

International Diabetes Foundation

KQ

key question

LDL

low-density lipoprotein

NCEP

National Cholesterol Education Program

NHANES

National Health and Nutrition Examination Survey

OSA

obstructive sleep apnea

SBP

systolic blood pressure

TG

triglycerides

WHO

World Health Organization

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