DOI 10.
1515/jpem-2012-0384      J Pediatr Endocr Met 2013; 26(7-8): 703–708
Cenk Aypak*, Özlem Türedi, Adnan Yüce and Süleyman Görpelioğlu
Thyroid-stimulating hormone (TSH) level in
nutritionally obese children and metabolic
co-morbidity
Abstract
Objective: In recent years, there has been increasing focus
on thyroid function in pediatric obese patients. Our aims
were to investigate whether there is an association between
serum thyroid-stimulating hormone (TSH) within the
normal range and body mass index (BMI), and to determine
if TSH levels correlate with metabolic risk factors in children.
Methods: A retrospective cross-sectional analysis was
carried out on 528 euthyroid, age- and sex-matched lean,
overweight, or obese children. Anthropometric indices,
blood pressure, fasting blood glucose, hepatic enzymes,
lipid profiles, TSH, free triiodothyronine (fT3), and free
thyroxine (fT4) were assessed from medical records and
compared among groups. Subjects with known presence
of diabetes, using medications altering blood pressure
and glucose or lipid metabolism, with TSH levels > 97.5
or < 2.5 percentile, or with autoimmune thyroid disease
were excluded.
Results: Hypertension, dyslipidemia, and elevated levels
of hepatic enzymes were found to be more common in
overweight and obese children (p < 0.001), and those
metabolic changes were significantly correlated with the
increase in BMI (p < 0.05). Serum concentrations of TSH
and fT3 within the normal range were higher in over-
weight and obese children (p < 0.01), and TSH was posi-
tively correlated with total cholesterol, triglycerides, and
systolic blood pressure (p < 0.05).
Conclusion: Our findings suggest that obese children have
higher serum TSH and fT3 levels even within the normal
range, and that an increase in TSH is associated with dys-
lipidemia and higher systolic blood pressure. It remains to
be seen whether TSH might serve as a potential marker of
metabolic risk factors in obese pediatric patients.
Keywords: children; dyslipidemia; hypertension; obesity;
thyroid hormones; thyrotropin.
*Corresponding author: Cenk Aypak, MD, Department of Family
Medicine, Diskapi Training and Research Hospital, Ankara 06110,
Turkey, Phone: +903123186981-514, Fax: +903123170287,
E-mail: cenkaypak@yahoo.com
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Özlem Türedi and Süleyman Görpelioğlu: Department of Family
Medicine, Diskapi Yildirim Beyazit Training and Research Hospital,
Ankara 06110, Turkey
Adnan Yüce: Division of Pediatrics, Diskapi Yildirim Beyazit Training
and Research Hopital, Ankara 06110, Turkey
Introduction
Childhood obesity is a worldwide health problem, and
its prevalence is increasing steadily and dramatically all
over the world (1). Obese children have a much greater
likelihood than normal-weight children of acquiring dys-
lipidemia, elevated blood pressure, and impaired glucose
metabolism, which significantly increase their risk for
cardiovascular and metabolic diseases (2). The ascend-
ing epidemiological curves of obesity, particularly in chil-
dren, and the associated metabolic burden, brought about
an estimation of decreased life expectancy at birth in the
USA during the first half of this century (3).
Although it is well known that hyperthyroidism leads
to weight loss and hypothyroidism is associated with
weight gain, there has been an increased interest in the
association between thyroid dysfunction and obesity.
An elevated serum level of thyroid-stimulating hormone
(TSH) with normal peripheral thyroid hormone concen-
trations, suggesting subclinical hypothyroidism, has been
consistently found in obese subjects (4, 5). A positive cor-
relation has also been found between weight gain during
5 years and a progressive increase in TSH concentrations
(6). These data suggest that thyroid function, even within
the normal range, could be one of several factors contrib-
uting to determining body weight in the general popula-
tion (7).
Thyroid function has been extensively investigated
in obese adults (8–13), but to a limited extent in the pedi-
atric obese population (14–21). Nevertheless, most of the
previous studies have focused their attention on patients
with thyroid dysfunction but also subjects with abnormal
TSH levels were included. Hence, the association between
small differences in thyroid hormone levels, as seen in
the general population without thyroid dysfunction, and
704      Aypak et al.: Thyroid function in pediatric obesity
body weight or body mass index (BMI) has not been fully
studied in the pediatric population. Additionally, the rela-
tion between thyroid function and lipids has been exam-
ined in the pediatric population only to a limited extent
(14). Therefore, the objectives of this study were to assess
the level of TSH and to determine the relation between
TSH level and lipid profiles in nutritionally obese euthy-
roid children and compare their results with lean controls.
Materials and methods
Subjects
To complete the study, the electronic medical files of all children who
attended the outpatient clinics of pediatrics (Dışkapı Yıldırım Beyazit
Training and Research Hospital, Ankara, Turkey) between April 2012
and October 2012 (a 6-month period) were retrospectively reviewed.
The medical records of lean, non-syndromal overweight and obese
children were analyzed. Among those, children whose thyroid hor-
mone levels were eligible were included in the study. According to
medical records, subjects with known presence of diabetes, using
medications altering blood pressure and glucose or lipid metabo-
lism, with TSH levels > 97.5 or < 2.5 percentile according to age, or
with autoimmune thyroid disease (positive antithyroidal peroxidase
and antithyroglobulin antibodies) were excluded (1 subject with dia-
betes, 3 with autoimmune thyroiditis, and 37 had serum TSH outside
the 2.5–97.5 percentile range). Incompleteness of records was the ex-
clusion criteria. Thus, 528 children (204 obese, 114 overweight, and
210 lean) were left for the analysis on the association between serum
TSH and BMI within the ‘normal TSH range’.
BMI was measured using weight (kg) divided by height square
(cm). Because BMI changes with age and sex, age- and sex-specific BMI
percentiles were calculated according to Turkish growth charts (22).
Overweight was defined as BMI between the 85 and 95 percentile for
the age and sex, and obesity as BMI >95 percentile for the age and sex.
The weight status was calculated as standard deviation score (SDS)-
BMI using population-specific data and Cole’s least mean square
method, which normalizes the BMI skewed distribution (23–25).
Age, sex, pubertal stage (determined by Tanner staging),
height, weight, waist circumference, hip circumference, systolic and
diastolic blood pressure, fasting blood glucose (FBG), alanine ami-
notransferase (ALT), γ-glutamyl transferase (GGT) levels, lipid pro-
files [including total cholesterol level (TC), low-density lipoprotein
cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C),
and triglycerides (TG)] and thyroid hormones [TSH, free triiodothyro-
nine (fT3), and free thyroxine (fT4)] were extracted from the records.
Hypertension in children is defined as systolic blood pressure
and/or diastolic blood pressure > 95 percentile for the age and sex.
Dyslipidemia is also defined as TC, LDL-C, and/or TG > 95 percentile
or HDL-C < 5 percentile for the age and sex. FBG, ALT, TC, HDL-C, and
TG were measured using an enzyme method with an autoanalyzer
(ADVIA 2400; Siemens Healthcare Diagnostics Inc., Tarrytown, NY,
USA), and thyroid hormones were measured by immunochemilumi-
nescent assay (Siemens Advia Centaur XP; Siemens Healthcare Di-
agnostics Inc.) in the laboratory of Dışkapı Yıldırım Beyazit Training
and Research Hospital. The TSH assay sensitivity was 0.002 mU/L.
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Statistical analysis
All values are expressed as mean ± SD. Skewness and kurtosis tests
were used to evaluate the normal distribution of the variables. Mean
differences were analyzed with one-way ANOVA with Bonferroni cor-
rection as a post hoc test for the normally distributed parameters,
and with the Kruskal-Wallis test followed by Dunn’s multiple com-
parison test for variables with non-Gaussian distribution. Correla-
tions between TSH levels and various variables were calculated with
the Pearson coefficient. Multiple linear regression analyses with TSH
as the dependent variable and age, sex, pubertal stage, anthropo-
metric measures, blood pressure, FBG, ALT, GGT levels, and lipid
profiles as independent variables were performed. A p value of < 0.05
was considered to indicate statistical significance. All analyses were
performed with the SPSS 18.0 program (SPSS Inc., Chicago, IL, USA).
Results
A total of 528 children [262 (49.6%) boys and 266 (50.4%)
girls] were included in the study. They were divided into
three groups [lean controls (n = 210; 39.8%), overweight
(n = 114; 21.5%), and obese (n = 204; 38.7%)] according to
their BMI. The age range of the study participants was
2–17  years old (mean age, 9 ± 3.29 years). The anthropo-
metric indices as well as age, sex, and blood pressure of
participants from the three groups are shown in Table 1.
No differences in age, sex, and pubertal stage among
the three groups were found. Hypertension was found in
1.9% (4 of 210) of lean, 3.5% (4 of 114) of overweight, and
6.3% (13 of 204) of obese subjects (p < 0.001). The increase
in systolic and diastolic blood pressure was significantly
correlated with the increase in BMI (r = 0.364, p = 0.000;
r = 0.315, p = 0.000, respectively). A total of 78 obese chil-
dren (38.2%) had dyslipidemia compared with 28 (32.5%)
overweight and 37 (17.6%) lean children (p = 0.000).
A comparison of laboratory results according to BMI
groups is shown in Table 2. The serum concentrations of
TSH and fT3 within the normal range were higher in over-
weight and obese children (p < 0.01), and the increase of
TSH and fT3 levels was correlated with the increase of
BMI (r = 0.137, p = 0.002; r = 0.197, p = 0.001, respectively).
However, no significant difference was found in fT4 serum
concentrations among the three groups (p = 0.631).
The increase in TSH serum concentration was sig-
nificantly correlated with the increase in TC (r = 0.086,
p = 0.047), TG (r = 0.130, p = 0.003), and systolic blood
pressure (r = 0.115, p = 0.009). No significant correlation
was found between TSH serum concentration and LDL-C
(r = 0.045, p = 0.3), HDL-C (r = 0.018, p = 0.674), ALT (r = 0.083,
p = 0.057), GGT (r = 0.044, p = 0.317), and diastolic blood
pressure (r = 0.63, p = 0.149).
 Aypak et al.: Thyroid function in pediatric obesity      705

Table 1 Age, sex, anthropometric indices, and blood pressure of the study group.

Lean Overweight Obese p-Value

BMI (kg/m2) < 85% BMI (kg/m2) 85%–95% BMI (kg/m2)  ≥  95%
(n = 210) (n = 114) (n = 204)

Age, years ± SD 9.2 ± 3.3 9.1 ± 3.3 8.7 ± 3.3 0.339

Male/female, n (%) 97 (46.2)/113 (53.8) 61 (53.5)/53 (46.5) 104 (49.6)/100 (50.4) 0.401
Prepubertal/pubertal, n (%) 143 (68.1)/67 (31.9) 79 (69.3)/35 (30.7) 137 (67.2)/67 (32.8) 0.385
SDS-BMI –0.13 ± 0.91 1.30 ± 0.031 2.10 ± 0.53 0.000
Waist circumference, cm 64.1 ± 9.6 71.2 ± 11.5 80.3 ± 13.3 0.000
Hip circumference, cm 74 ± 11.7 80.2 ± 12.5 86.8 ± 14.2 0.000
Systolic BP, mm Hg 99.1 ± 12.7 102.3 ± 13.4 110.8 ± 13.6 0.000
Diastolic BP, mm Hg 59.4 ± 8.9 62.6 ± 8.2 66.1 ± 9.1 0.000

BMI, body mass index; SD, standard deviation; SDS-BMI, SD score body mass index; BP, blood pressure.

Multiple regression analyses were conducted to
examine the relation between TSH and various poten-
tial predictors. The model with all predictors produced
R2 = 0.830, F(3, 489) = 45.67, p < 0.001. Age and puberty were
found to be negatively correlated with TSH, whereas BMI
systolic blood pressure, TC, and TG were positively and
significantly correlated with TSH, indicating that those
with higher levels of these variables tend to have higher
TSH levels (Table 3).
Discussion
The prevalence of childhood obesity is increasing world-
wide, leading to an increase in obesity-related health
problems, which are expected to have a serious impact
on the physical and psychosocial well-being of children
in the coming decades as well as on life expectancy,
health-care costs, and national economies (4). Recently, it
has been suggested that in the 21st century, obese children
may die before their parents, due to a potential decline in
life expectancy (11). As a transitional society, Turkey has
also shown an increase in obesity figures in the past three
decades in both adults and children (26).
Many complications are associated with children
being overweight or obese, even at a very young age.
These include impaired glucose tolerance, elevated blood
pressure, and dyslipidemia (12). Our study confirms that
hypertension, high serum TGs and LDL, and low serum
HDL cholesterol levels were more prevalent among
overweight and obese children and significantly associ-
ated with BMI. It is well known that obesity is linked to
hyperinsulinemia resulting impaired glucose tolerance,
and the liver plays a central role in the etiopathogenesis
(27). The most common laboratory sign of liver disease
in obesity is elevated transaminase levels (28). Our find-
ings have revealed that ALT and GGT levels were higher

Table 2 Comparison of laboratory features of lean, overweight, and obese children.

Lean Overweight Obese p-Value

BMI (kg/m2) < 85% BMI (kg/m2) 85%–95% BMI (kg/m2)  ≥  95%
(n = 209) (n = 113) (n = 204)

Total cholesterol 146.4 ± 25.7 154.3 ± 24.3 160.7 ± 28.2 0.000

Triglycerides, mg/dL 78.8 ± 42.6 91.19 ± 54.9 105.9 ± 65.5 0.000
LDL, mg/dL 77 ± 20.7 85.5 ± 19.5 89.4 ± 22.6 0.000
HDL, mg/dL 49.4 ± 11.5 47.7 ± 11 46 ± 9.7 0.004
Glucose, mg/dL 72.4 ± 9.4 73.5 ± 9.9 73.6 ± 10.9 0.426
ALT, mg/dL 16.8 ± 7.4 17.5 ± 12.6 21.3 ± 12.4 0.000
GGT, mg/dL 9.9 ± 4 11.2 ± 4.6 13.1 ± 8.3 0.000
TSH, mIU/L 2.1 ± 0.9 2.2 ± 0.8 2.4 ± 1.02 0.003
fT3, pg/mL 3.7 ± 0.5 3.8 ± 0.5 3.9 ± 0.5 0.005
fT4, ng/dL 1.6 ± 0.1 1.6 ± 0.1 1.06 ± 0.2 0.631

BMI, body mass index; LDL, low-density lipoprotein; HDL, high-density lipoprotein; ALT, alanine aminotransferase; GGT, γ-glutamyl trans-
ferase; TSH, thyroid-stimulating hormone; fT3, free T3; fT4, free T4.

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706      Aypak et al.: Thyroid function in pediatric obesity
Table 3 Multiple linear regression model with serum TSH as a
continuous variable.
Predictor variable β p-Value
Age –0.234
Sex 0.043
Puberty –0.275
Systolic blood pressure 0.182
Diastolic blood pressure 0.057
SDS-BMI 0.193
Total cholesterol, mg/dL 0.252
Triglycerides, mg/dL 0.172
LDL, mg/dL 0.065
HDL, mg/dL 0.067
Glucose, mg/dL 0.023
ALT, mg/dL 0.042
GGT, mg/dL 0.016
TSH, thyroid-stimulating hormone; SDS-BMI, SD score body mass
index; LDL, low-density lipoprotein; HDL, high-density lipoprotein;
ALT, alanine aminotransferase; GGT, γ-glutamyl transferase.
in overweight and obese children and were significantly
associated with BMI. Although none of the children in
our study were found to have increased levels of FBG, the
elevated transaminase levels suggest possible liver injury
and may indicate the development of hyperinsulinemia in
the near future among obese children.
In recent years, there has been an increasing focus on
thyroid function and obesity. While it has not been con-
firmed by all studies (29), higher serum TSH concentra-
tions are consistently found in obese children and adults
compared with lean individuals (12, 16, 17, 30). Thus, evi-
dence suggests that TSH seems to be positively related
to the degree of obesity (31–37). Additionally, a moder-
ate increase in total T3 or fT3 levels has been reported in
obese subjects (33–35). However, little was known about
levels of thyroid hormones within the normal range in
obese children compared with age- and sex-matched
normal-weight controls. This is one of the few studies in
the literature that compares TSH levels within the normal
range according to age and sex, among lean, overweight,
and obese children, and our findings confirm that obese
children have significantly higher serum TSH and fT3
levels even within the normal range in comparison with a
matched control group. It is unclear whether the changes
in thyroid hormones are a cause or a consequence of
obesity. Although our data do not prove any causal asso-
ciation, there are plausible biological explanations in the
literature. It was shown that progressive fat accumula-
tion was associated with a parallel increase in TSH and
fT3 levels (3, 30, 34, 38, 39). This finding suggests a high
conversion of T4 to T3 in obese patients due to increased
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deiodinase activity to improve energy expenditure (34).
Also, it was reported that TSH receptors are less expressed
on adipocytes of obese vs. lean individuals despite the
higher plasma TSH levels (35). This might induce down-
0.000 regulation of thyroid hormone receptors and thyroid
0.335 hormone action, thereby further increasing plasma TSH
0.000
and fT3 concentrations and constituting a condition of
0.029
0.406
peripheral thyroid hormone resistance (35). Also, a posi-
0.027 tive correlation has been identified between serum leptin
0.019 and serum TSH levels in obese individuals (31), which
0.030 could reflect the positive association between TSH and
0.443 BMI reported in some individuals (3, 30, 38, 39). Recently,
0.417
it has been shown that the changes in thyroid hormone
0.607
0.374 levels normalized in obese children after losing weight
0.747 (30), which supports the hypothesis that the alterations
of thyroid hormones seem to be a reversible consequence
of the weight status. However, the impact of weight loss
on thyroid hormone levels within normal values remains
uncertain and should be further studied.
Our results have revealed that serum TSH levels cor-
related negatively with chronological age and that TSH
concentrations in all age groups showed no sex differ-
ences, which are consistent with previous studies (40, 41).
Moreover, our findings have underscored the fact that TSH
levels are not associated with sexual development (41).
Previous studies did not find any significant difference
in lipid profile, except TG levels, between obese partici-
pants with hyperthyrotropinemia and those with normal
thyroid functions (14, 17, 42). Our results have shown that
not only TG but also TC was significantly correlated with
TSH even within the normal range; however, it is unclear
whether the changes in TC and TG are a cause or a con-
sequence of altered thyroid functions in those children.
Our finding should be further investigated because it has
been assumed that TSH levels except overt thyroid dys-
function do not affect lipid profile. Additionally, systolic
blood pressure was found to be significantly correlated
with serum TSH concentration. The results of the current
study may indicate that increased TSH levels even within
the normal laboratory range could be an independent risk
factor for dyslipidemia and systolic hypertension in pedi-
atric obese children.
Our study has a few potential limitations. First, it was
performed retrospectively. Second, testing the plasma
insulin concentration of an obese child is not a routine
practice in our outpatient clinics. Therefore, we could not
determine the fasting plasma insulin level or the HOMA-IR
(homeostasis model assessment for insulin resistance),
and we could not analyze whether there is an association
between serum TSH and plasma insulin level. However,
our study has several strengths. First, careful correction

for age and sex status excludes the potential impact of
those factors on thyroid hormone levels. Second, the study
subjects were relatively homogenous: all resided in a rela-
tively isolated area, which eliminates possible confound-
ing factors such as considerable differences in thyroid
function that may be seen between populations probably
due to a number of environmental factors, of which iodine
intake level seems to be of major importance (43, 44).
In conclusion, our findings suggest that TSH and
BMI were positively correlated even within normal TSH
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