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June 7, 2022

Pediatric Obesity Research Update | June 2022 Review

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Each month, the OMA Pediatric Committee reviews a pediatric-focused obesity research update to help keep you up to date about the latest findings. This month's update addresses pediatric obesity and musculoskeletal development.

The Role of Obesity in Pediatric Orthopedics

Article Summary

Obesity has a deleterious effect on the mechanics and physiology of the growing skeleton. This can be seen in fracture risk, severity of fractures, and delay in diagnosis of common pediatric orthopedic issues such as scoliosis. Read the full article.

Article Review

Although certain conditions, such as Blount's disease and slipped capital femoral epiphysis, have been associated with obesity in children, there is growing evidence that obesity has adverse effects on the mechanics and physiology of the growing skeleton. Obesity also impacts the patterns and severity of pediatric fractures. It may limit conservative management approaches due to the increased risk of loss of fracture reduction in the child with obesity. Obesity can also alter the presentation of common pediatric orthopedic conditions such as scoliosis, leading to a delay in diagnosis.

About 40% of bone mineral accrual occurs within two years of the adolescent growth spurt, with 90% of bone deposition occurring by age 18. Any deleterious effect that occurs at that age can affect bone health throughout the life cycle. Increased body fat in adolescents negatively affects the accrual of peak bone mass.

Central obesity appears to be more metabolically harmful to bone in children than peripheral adiposity. These effects are mediated through insulin resistance, increased inflammatory cytokine production, altered leptin production (which has an inhibitory effect on bone cortical size), and vitamin D deficiency. Abdominal obesity also produces systemic inflammation and inflammatory cytokines, which directly promote bone resorption, leading to osteopenia/osteoporosis.

Fat-soluble vitamin D is sequestered in adipose tissue, decreasing bioavailability for bone remodeling. Vitamin D deficiency, increased intake of simple carbs, and inadequate consumption of calcium-rich foods increase the risk of osteoporosis in children.

Children with obesity are at higher risk for fractures due to trauma. These fractures also tend to be more severe than in a normal-weight child with the exact mechanism of injury. Children with obesity tend to have bigger bones, greater bone mineral content for height, greater bone strength, and earlier maturation. Despite these structural properties, obesity-induced endocrinological changes and nutritional deficiencies lead to a lower bone mass ratio compared to overall patient weight. Children with obesity tend to have poorer balance and, combined with the lower ratio of bone mass to weight ratio, during a fall, will generate more force than age-matched normal-weight peers and are therefore at increased fracture risk.

Obesity can make conservative treatment of fractures more challenging. The increased soft tissue limits the cast treatment's effectiveness, which limits the appropriate stabilization of the injured bone. Reduction of the fracture may be lost, and surgical intervention is needed more often than in a normal-weight child. Children with obesity who are managed with casting should be monitored closely.

Pediatric patients with obesity may be at greater risk for anesthetic and other peri-operative complications. While the costs of providing acute care are not different for a child with overweight or obesity, it is more expensive to take care of a child with obesity who needs to be hospitalized for orthopedic surgery.

Obesity is a modifiable risk factor that negatively affects skeletal development in children. Some of these changes can persist over a lifetime. Addressing obesity early in pediatric patients can have a positive, long-lasting impact on bone health.

Additional Resources

Find more resources curated by OMA's Pediatric Committee on our Pediatric Resources page. There, you'll find additional article reviews on various topics related to obesity as well as public resources for clinicians and families.

Nowicki, P., Kemppainen, J., Maskill, L., & Cassidy, J. (2019). The Role of Obesity in Pediatric Orthopedics. Journal of the American Academy of Orthopaedic Surgeons. Global research & reviews, 3(5), e036.