International Journal of Obesity (2005) 29, S97–S100

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PAPER
Adipose tissue and metabolic effects: new insight into
measurements
A Pietrobelli1*, AL Boner1 and L Tatò1
1
Pediatric Unit, Verona University Medical School, Verona, Italy

BACKGROUND: Epidemiologic evidence supports the theory that the relation between obesity and disease risk begins early in
life, and those risk factors for disease track, or remain at a similar level, with advancing age, growth, and development. The fat
tissue, once considered as a depot for energy substrate, is a metabolically active tissue. The fat cells produce agents that regulate
a host of physiological processes directly related to carbohydrate and fat metabolism and the development of cardiovascular
disease and type 2 diabetes.
AIM: To discuss fat tissue, and fat distribution in relation to body composition measurements, with particular emphasis on
imaging techniques (ie, dual energy X-ray absorptiometry (DXA), computed tomography (CT), and magnetic resonance
imaging (MRI)) and its relationship with metabolic and cardiovascular heath variables mediated by the metabolic characteristics
of the adipose tissue.
DISCUSSION: In sum, the medical and physiological health complications of childhood obesity are well documented. Imaging
methods are considered the most accurate means available for in vivo quantification at the tissue–organ level and the methods of
choice for calibration of field methods designed to measure adipose tissue.
International Journal of Obesity (2005) 29, S97–S100. doi:10.1038/sj.ijo.0803079

Keywords: body composition measurements; pediatric; body fat; visceral adipose tissue; subcutaneous adipose tissue

Introduction weight during the same period is about 260%. The

Obesity results when intake exceeds expenditure and both
sides of the energy-balance equation must be considered in
concert in research on the etiology of childhood obesity.1
Epidemiologic evidence supports the theory that the relation
between obesity and disease risk begins early in life, and that
risk factors for disease track, or remain at a similar level, with
advancing age, growth, and development.2
During growth, the human body increases in size and
changes proportion of various components due to hormone
mediators.3 Growth is a complex, biological process regu-
lated by multiple factors. These factors include genetic,
nutrition intake, physical activity, age, gender, and endo-
crine balance, all of which influence a child’s height and
body composition during the growth years. Clinical assess-
ment of growth and nutritional status is enhanced by
accurate measurement of body composition. For a healthy
infant born at term, the average increase in fat mass (FM)
during infancy, is about 600%, whereas the increase in body
*Correspondence: Dr A Pietrobelli, Pediatric Unit, Verona University
Medical School, Policlinic GB. Rossi, Via delle Menegone 10, Verona
37134, Italy.
E-mail: angpie@tin.it
accumulation of FM is very rapid during the first 4–6 months
of life. As a percentage of fat-free mass (FFM), water decreases
throughout infancy whereas protein and mineral increase.
However, the quantitative nature of these changes remains
uncertain. Recently, Fomon and Nelson4 revisited the body
composition of the reference infant to permit initial
estimates of the gain in energy and specific nutrients during
selected age intervals.
The aim of our article is to discuss fat tissue, and fat
distribution in relation with body composition measure-
ments, with particular emphasis on imaging techniques and
their relationship with metabolic and cardiovascular health
variables mediated by the metabolic characteristics of the
adipose tissue.
Fat mass
The fat tissue, once considered as a depot for energy
substrate, is a metabolically active tissue.5 The fat cells
produce agents that regulate a host of physiological
processes directly related to carbohydrate and fat metabo-
lism6 and the development of cardiovascular disease and
type 2 diabetes.2
 Pediatric adipose tissue measurements
A Pietrobelli et al
S98
FM is the most variable component of body composition,
and between-individual variability ranges from approxi-
mately 6–60% of total body weight.7 At birth average FM
is about 10–15%, increases to 30% at 6 months of age
and graduallys decrease during early childhood.8 Between
5 and 8 y of age a ‘preadolescent’ wave or ‘adiposity rebound’
occurs9 and then, in girls percent total fat increases from
an average of 20 to 26% between 9 and 20 y, while in
boys it decreases from 17 to 13% after 13 y of age as FFM
increases.10
Two critical periods for the development of overweight in
pediatric age are the prenatal period and adolescence. Also
‘adiposity rebound’ could be considered as the third.11 Both
low and high body mass appear to arise during the prenatal
period.12 Infants with high birth weight appear to have an
increased risk of subsequent overweight. Effects of the
intrauterine environment on cell numbers, satiety centers
in the brain, and endocrine function represent mechanisms
that account for the apparent prenatal influence on
excessive weight at birth.13 Early adiposity rebound appears
associated with an increased risk of overweight in adulthood
as well as adolescence and represents the third critical period
when overweight occur and may increase the risks of the
sequelae of obesity in adulthood.13
Measures of body composition and total body fatness
change with growing, developing, and aging. Specific cutoff
values for children and adolescents have been suggested
based on specific health-related criteria. However, defining
obesity standards in children and adolescents remains
controversial, and widely accepted percent body fat (%BF)
criteria have not yet to be developed. Several studies reported
the relationship between adiposity and metabolic risk factors
in children and adolescents.2,14,15
Fat distribution
Fat distribution refers to the relative amount of fat in the
primary compartments where adipose tissue and fat are
stored in the body.16 The anatomical distribution of adipose
tissue shows distinct patterns of change with age and gender
maturation. Regional fat represents a single variable as
subcutaneous adipose tissue or visceral adipose tissue.
Subcutaneous adipose tissue is referred to as ‘fat patterning’
to distinguish it from visceral adipose tissue, the accumula-
tion of internal adipose tissue.16 In general, subcutaneous
adipose tissue increases in the trunk in boys during
adolescence and gluteal femoral tissue increases in girls.
These changes are associated with stage of sexual matura-
tion, sex hormone levels, and changes in plasma lipid or
lipoprotein cholesterol concentration.17
Several other factors influence both visceral and subcuta-
neous adipose tissue. Total FM is an important determinant
of visceral adipose tissue, but it is not completely clear
whether increasing adiposity in children and adolescents is
related to increasing visceral adipose tissue.2 Recently, we
pooled together all the data on MRI subcutaneous and
International Journal of Obesity
visceral adipose tissue measurements in children available in
the literature in order to analyze the effect of age, gender,
pubertal status, and ethnicity and we found differences in
total and regional adiposity due to ethnicity, gender, and
pubertal status relationship.18 Hormones per se also play a
fundamental role in determining body fat distribution; in
fact, earlier onset of puberty implies that the development of
an adult body fat pattern will occur at an accelerated way
that may lead to earlier onset of adulthood diseases.2 Dietary
factors and physical activity influence adipose tissue dis-
tribution in adults.19,20 Very few studies looked at these
relationships in children and it was found that in obese
children aerobic training program influence changes in
subcutaneous adipose tissue.21
Finally, regional adiposity, lipid and insulin action are
closely related. Changes in lipid and lipoprotein concentra-
tions may result from insulin resistance and the accompany-
ing hyperinsulinemia in children and adolescents.14,15
Fat measurements
Although adipose tissue cannot be directly measured in
living humans, various, indirect measures are available for
use with children and adolescents.1 These measures include
the body mass index (BMI: weight in kg/height in m2), and
weight for-stature indexes, skinfold measures, electrical
bioimpedance analysis, dual energy X-ray absorptiometry
(DXA) and imaging techniques (magnetic resonance ima-
ging (MRI); and computed tomography (CT)).22 We review in
detail DXA and MRI, while emphasizing the importance of
assessment of fat distribution in children and adolescents.
Dual energy X-ray absorptiometry
DXA quantifies the relative attenuation of two main photon
peaks as they pass through tissue. The relative attenuation of
the two discrete photon streams is a function of tissue
elemental composition. This phenomenon can be described
using the ratio (R-value) of low to high photon energy
attenuation. The R-value at any given energy for each
element is known and constant.23,24 Bone, rich in calcium
and phosphorous, has a high relative attenuation and R-
value; fat, which is mainly low atomic number hydrogen and
carbon, has a low relative attenuation and low R-value; and
lean soft tissue with oxygen and electrolytes have an
intermediate R-value.23 Systems conceptually measure each
pixel’s R-value as they pass over regions of the whole body
and then reconstruct three compartments, bone mineral
content, FM, and FFM using manufacturer-specific recon-
struction algorithms (Figure 1).23 The use of DXA to assess
body composition in children and youth is an ideal one
and it is a valid method to track changes over time. DXA
estimates of bone mineral, soft tissue, and fat are not greatly
affected by the hydration level of FFM. Theoretical analysis24
showed that the natural variation in FFM hydration alters
DXA estimates of percent fat less than 1%.

Fat
Soft-Tissue
Water
Body
Weight Lean
Proteins
Glycogen
Minerals
Bone
Minerals
Figure 1 Dual energy X-ray absorptiometry model. Modified from refe-
rence 23.
This technique has the potential to substantially improve
the feasibility of body composition analysis with children for
whom other laboratory techniques may be impractical (eg,
underwater weighing). The greatest advantage of DXA may
be the ability to assess regional body composition (trunk,
arms, and legs). Nutritional status of diseased individuals can
be evaluated by analyzing the individual compartments of
the body. We propose that DXA has great potential as both a
pediatric research tool and a clinical tool if the specific
characteristics of the system being used are recognized.22 An
example of a research use of DXA that may lead to clinical
application is the prediction of comorbidity risk in obese
children and adolescents.25 In prepubertal children, a cutoff
point of 33% body fat estimated by DXA had a good
sensitivity to identify an adverse risk factor profile.25 Studies
showed that a greater than 30% body fat lipid profile
worsens in girls.26,27 In boys, a 20% body fat26 and a 25%
body fat27 were suggested as cutoffs for obesity in children
and adolescents based on cardiovascular disease risk.
DXA measures total abdominal fat and may provide a
strong index, but this technique cannot resolve subcuta-
neous from intra-abdominal adipose tissue,1 although Loh-
man28 suggested that DXA abdominal fat in combination
with skinfold thicknesses could be used to estimate intra-
abdominal fat.
Imaging
Computerized axial tomography (CT) and MRI provide
investigators with the opportunity to evaluate tissue-system
level components in vivo.29 In particular, accumulation of
visceral adipose tissue is related with adverse health and the
effect of fat distribution on disease risk is a fundamental
issue.30 In children and adolescents, recent studies found a
correlation between central fat and type 2 diabetes mellitus
Pediatric adipose tissue measurements
A Pietrobelli et al
S99
and cardiovascular disease.30 Using imaging we could under-
stand the origin of the significant relationship between
visceral adipose tissue and adverse health and also explain
the influence of ethnic and gender differences in adipose
tissue distribution.18
MRI for pediatric body composition measurement is
relatively new and the lack of radiation exposure associated
with its use makes it more applicable than CT. On the other
hand, MRI is to our knowledge the only method in vivo used
to study fetal body composition31 and it could help to
understand the physiological and pathological condition in
the newborn. The reproducibility of MRI for subcutaneous
adipose tissue in the infant is between 2.4 and 4.0% and
approximately 17% for visceral adipose tissue.32 As we noted
before, tissue composition may vary with age, and in
neonates fat content of adipose tissue is 66% and gradually
increases to 80% at the age of 13 y.33
The most common use of MRI in body composition
research is the measurement of abdominal adipose tissue
distribution, and this technique is capable of distinguishing
between subcutaneous and visceral adipose tissue. Thus, we
could provide new insight into the relationship between
abdominal obesity and related comorbidities.34
A single slice or several slices could be obtained. One scan
is sufficient to determine fat tissue area, whereas several scan
slices are needed to estimate fat tissue volume. A single scan
at the L4–L5 or umbilicus level is typically used to measure
visceral and subcutaneous abdominal fat areas.29 Advances
in the measurement of internal as well as subcutaneous
adipose tissue with MRI allow investigators to study
compartments that were undistinguishable (ie, intrathoracic
and intra-abdominopelvic areas) and could help to under-
stand relations with metabolic factors.16
Comments and conclusion
In sum, the medical and physiological health complications
of childhood obesity are well documented. Children who
were at risk for overweight or who were overweight were 2.4
times as likely as normal weight children to have elevated
total cholesterol, diastolic blood pressure, low-density lipo-
protein cholesterol, high-density lipoprotein cholesterol,
systolic blood pressure, triglycerides, and fasting insulin.35
Several of these associations differed between white and
black subjects, and by age.36 The association of central
adiposity with the mentioned risk factors is clearly stronger
for obese children and adolescents. Imaging methods are
considered the most accurate means available for in vivo
quantification at the tissue–organ level and the methods of
choice for calibration of field methods designed to measure
adipose tissue.
It is fundamental to underline that an enlarged abdomen
and an higher amount of trunk fat deposition in obese
children and adolescents are consistently related with a
deterioration of lipid and metabolic profiles.16 In children
and adolescents, insulin sensitivity and hyperinsulinemia
International Journal of Obesity
 Pediatric adipose tissue measurements
A Pietrobelli et al
S100
are independently related to circulating lipid after adjusting
for adiposity and this relation could be exacerbated by
high accumulation of intra-abdominal fat.2 Using imaging
techniques, a tremendous variation in the amount of
intra-abdominal fat was found, and visceral fat begins to
accumulate in early childhood. This implies that to be
effective, intervention to prevent obesity in childhood and
adolescence must begin at a very early stage.
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