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 as well as 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 and 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 accrural 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 accrural 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 (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, as well as 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 same 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 ratio of bone mass when compared with 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 effectiveness of cast treatment is limited by the increased soft tissue, which limits 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 costs of providing acute care is not different in a child with overweight or obesity, it is more expensive to take care of the child with obesity who needs to be hospitalized for orthopedic surgery.
Obesity is a modifiable risk factor which negatively affects skeletal development in children. Some of these changes can persist over a life time. 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.