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Am J Clin Nutr 2007;86:33 40. Printed in USA. 2007 American Society for Nutrition 33
34 FREEDMAN ET AL
the 19931994 examination. Written informed consent was ob- Risk factors
tained from all parents, and study protocols were approved by Concentrations of serum total cholesterol and triacylglycerols
human subjects review committees at the Tulane University were measured by using enzymatic procedures in a centralized
School of Public Health and Tropical Medicine. laboratory that met the requirements of the CDCs Lipid Stan-
Of the 3135 children and adolescents (aged 517 y) examined, dardization Program. For LDL- and HDL-cholesterol measure-
we excluded 9 girls who reported being pregnant, 7 children who ments, we used a combination of heparin-calcium precipitation
were not white or black, 30 children who reported taking insulin and agar-agarose gel electrophoresis (27). Plasma insulin mea-
(or were unsure), 13 children for whom we did not have a systolic surements were obtained with the use of a radioimmunoassay
(SBP) or diastolic (DBP) blood pressure measurement, and 14 procedure (Phadebas Insulin Kit; Pharmacia Diagnostics AB,
children for whom information on measurements of waist, Uppsala, Sweden).
weight, or height was missing; these categories were not mutu- As previously described (23), sitting SBP and DBP in the right
ally exclusive. Of the remaining 3066 children, cholesterol (total, arm were measured 6 times by trained observers with a mer-
LDL, and HDL) and triacylglycerol determinations were avail- cury sphygmomanometer (Baumanometer; WA Baum Co Inc,
able for 2961. Nonfasting children were excluded from the anal- Copiague, NY). The cuff size was based on the length and
yses of triacylglycerol and fasting insulin concentrations, and circumference of the upper arm and was chosen to be as large
another 130 children did not have an insulin determination. After as possible without having the elbow skin crease obstruct the
these exclusions, sample sizes for the various risk factors are stethoscope (28).
3066 (for SBP and DBP), 2961 (for LDL and HDL cholesterol), The distributions of lipid and lipoprotein concentrations in the
2624 (for triacylglycerol), and 2494 (for insulin). Bogalusa Study were similar to those in the third National Health
Because obesity is associated positively with LDL cholesterol
TABLE 2
Classification of adverse risk factor by BMI-for-age z score and waist-to-height ratio1
yielded multiple R2 values that were only slightly higher than had a high BMI-for-age relative to waist-to-height ratio (6 upper
those obtained with the use of either index. For example, the right cells; x 0.21) was almost identical to the mean measure
multiple R2 for the risk factor sum based on both BMI-for-age among children who had a high waist-to-height ratio relative to
and waist-to-height ratio was 0.34, whereas the R2 for each index BMI-for-age (6 lower left cells; x 0.19; P 0.88). Compa-
alone was 0.32. rable analyses for the individual risk factors indicated that chil-
Despite the similarity of the multiple R2 values for the 2 in- dren with a relatively high waist-to-height ratio had slightly
dexes, additional analyses indicated that associations with BMI-
for-age were more curvilinear than those with waist-to-height
ratio. Predicted measures of several risk factors based on regres- 120 120
sion models containing either BMI-for-age (left panels) or waist- SBP (mm Hg)
100 100
to-height ratio (right panels) for an 11-y-old white girl are shown
in Figure 1. (Predicted measures for boys and black children TG
80 80
would be shifted vertically, but they would parallel the curves in (mg/dL)
Figure 1.) Nonlinearity was most evident in the relation of BMI- 60 60
for-age to concentrations of triacylglycerol (upper left panel), HDL-C
fasting insulin, and the risk factor sum (bottom left panel) but was 40 (mg/dL) 40
also observed for SBP and HDL cholesterol. Furthermore, for -2 -1 0 1 2 3 0.4 0.5 0.6 0.7
TABLE 4
Measures of the risk factor sum cross-classified by BMI-for-age and waist-to-height ratio1
BMI-for-age percentile
0.426 (n 869) 1.5 2.3 (623) 1.0 2.4 (240) 1.6 2.9 (4) 0.9 3.3 (2)
0.4260.466 (n 825) 1.0 2.5 (233) 0.4 2.4 (468) 0.2 2.5 (115) 1.1 1.7 (9)
0.4670.512 (n 382) 1.4 2.0 (13) 0.4 2.4 (107) 1.1 2.6 (187) 1.6 2.4 (75)
0.513 (n 417) (0) 0.7 2.2 (10) 1.6 2.8 (76) 3.3 2.5 (331)
1
All values are x SD; n in parentheses. Four hundred forty-five children had a high BMI-for-age relative to waist-to-height ratio (6 upper right cells);
439 children had a high waist-to-height ratio relative to BMI-for-age (6 lower left cells), and 1609 children were concordant for measures of BMI-or-age and
waist-to-height ratio (shaded cells along diagonal).
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