Blood Pressure

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Truncal pattern of subcutaneous fat distribution

is associated with obesity and elevated blood
pressure among children and adolescents

Ying-Xiu Zhang, Shu-Rong Wang, Jin-Shan Zhao & Zun-Hua Chu

To cite this article: Ying-Xiu Zhang, Shu-Rong Wang, Jin-Shan Zhao & Zun-Hua Chu (2017):
Truncal pattern of subcutaneous fat distribution is associated with obesity and elevated blood
pressure among children and adolescents, Blood Pressure, DOI: 10.1080/08037051.2017.1369000

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Published online: 23 Aug 2017.

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 BLOOD PRESSURE, 2017
https://doi.org/10.1080/08037051.2017.1369000

ORIGINAL ARTICLE

Truncal pattern of subcutaneous fat distribution is associated with obesity

and elevated blood pressure among children and adolescents
Ying-Xiu Zhanga
, Shu-Rong Wangb
, Jin-Shan Zhaoa and Zun-Hua Chua
a
Shandong Center for Disease Control and Prevention, Shandong University Institute of Preventive Medicine, Jinan, Shandong, China;
b
Shandong Blood Center, Jinan, Shandong, China

ABSTRACT ARTICLE HISTORY

Background: The association between elevated blood pressure (BP) and childhood obesity has Received 23 May 2017
been documented in several studies. However, little is known the difference in BP levels among Revised 23 July 2017
children and adolescents with different patterns of fat distribution. The present study examined Accepted 14 August 2017
the association of subcutaneous fat distributional pattern with obesity and elevated BP among
Downloaded by [Australian Catholic University] at 18:59 27 August 2017

children and adolescents. KEYWORDS

Methods: A total of 38,687 students (19,386 boys and 19,301 girls) aged 717 years participated Skinfold thickness;
in the study. Body mass index (BMI) cutoff points recommended by the International Obesity distribution; obesity; blood
Task Force (IOTF) were used to define overweight and general obesity. Abdominal obesity was pressure; adolescent
defined as waist-to-height ratio (WHtR)  0.5. Relatively high BP (RHBP) status was defined as sys-
tolic blood pressure (SBP) and/or diastolic blood pressure (DBP)  95th percentile for age and
gender. All individuals were classified into four groups (Q1Q4) according to the age and sex-
specific quartiles of subscapular to triceps skinfold thickness ratio (STR), the prevalence rates of
overweight, general obesity, abdominal obesity and RHBP among the four groups were
compared.
Results: In both boys and girls, significant differences in the prevalence rates of overweight,
general obesity, abdominal obesity and RHBP were observed among the four groups, an increas-
ing trend was observed from the Q1 (STR <25 th) group to the Q4 (STR  75th) group (p < 0.01).
Children and adolescents with high STR had higher prevalence of overweight, obesity and RHBP
than their counterparts with low STR (p < 0.01).
Conclusion: Truncal pattern of subcutaneous fat distribution is associated with obesity and ele-
vated BP among children and adolescents. Public health attention should not only focus on the
amount of body fat, but also on the distributional pattern of body fat.

Introduction However, BMI cannot distinguish between fat and fat-

The prevalence of obesity in children and adolescents,
with its rapid rising trend [1,2] and attendant health
risks [3], has become an important public health con-
cern facing the world today [4]. In 20092010, 18.2%
of US children and adolescents aged 619 years were
obese [5]. China is the largest developing country in
the world, along with the rapid economic growth,
children and adolescents are becoming increasingly
obese [6]. It was estimated that 5.1% of Chinese chil-
dren and adolescents aged 718 years were obese in
2010 [7].
Body mass index (BMI) is perhaps the most com-
monly used measure for defining overweight and
obesity in clinical practice and population surveys.
free mass, it provides no information on body fat dis-
tribution. Several studies have shown that compared
with BMI, body fat distribution plays a greater role in
the development of obesity-related complications such
as cardiovascular disease and type 2 diabetes [8].
Skinfold thickness (SFT) measurements are widely
used to assess body fat because the measurements are
non-invasive, simple and less expensive than labora-
tory-based techniques. Furthermore, subscapular to
triceps skinfold thickness ratio (STR) as an indicator
of trunk versus peripheral distribution of body fat has
been widely applied in large-scale epidemiological
studies [911].
The association between elevated blood pressure
(BP) and childhood obesity has been documented in

CONTACT Ying-xiu Zhang sdcdczyx@163.com Shandong Center for Disease Control and Prevention, Shandong University Institute of Preventive
Medicine, 16992 Jingshi Road, Jinan, Shandong 250014 China; Shu-Rong Wang plwangshurong@163.com Shandong blood center, 22 Shanshi East
Road, Jinan, Shandong 250014, China
#Shu-Rong Wang and Ying-Xiu Zhang have contributed equally to this work should be considered as co-first authors.
2017 Informa UK Ltd, trading as Taylor & Francis Group
 2 Y.-X. ZHANG ET AL.
several studies. However, little is known the difference
in BP levels among children and adolescents with dif-
ferent patterns of fat distribution. In this article, based
on a large sample, we report the association of sub-
cutaneous fat distributional pattern with obesity and
elevated BP among children and adolescents in
Shandong, China.
Subjects and methods
The study was approved by the Ethical Committee of
the Shandong Center for Disease Control and
Prevention, Shandong, China.
Study population
Downloaded by [Australian Catholic University] at 18:59 27 August 2017
Data for this study were obtained from a large cross-
sectional survey of schoolchildren. A total of 38,687
students (19,386 boys and 19,301 girls) from 17 dis-
tricts in Shandong Province, students of Han nation-
ality, aged 717 years, participated in the National
Surveys on Chinese Students Constitution and
Health, which were carried out in September to
October 2014. The sampling method was stratified
multistage sampling based on selected primary and
secondary schools. Six public schools (two primary
schools, two junior high schools, and two senior high
schools) from each of the 17 districts in Shandong
were randomly selected and invited to participate in
the study. From the selected schools, two classes in
each grade were selected, and all students of the
selected classes were invited to join the study. All sub-
jects were primary and secondary students, ranging
from 7 to 17 years of age, and all were of Han ances-
try that accounts for 99.32% of the total population
in Shandong. All subjects voluntarily joined this study
with informed consents.
Measurements
All measurements were performed by a team of
trained health professionals in each of the 17 districts.
Each professional is required to pass a training course
for anthropometric measurement organized by the
investigation team in Shandong. All measurements
were taken using the same type of apparatus and fol-
lowed the same procedures [12]. Height without shoes
was measured using metal column height-measuring
stands to the nearest 0.1 cm. Weight was measured
using lever scales to the nearest 0.1 kg while the sub-
jects wore their light clothes. Waist circumference
(WC) was measured midway between the lowest rib
and the superior border of the iliac crest with an
inelastic measuring tape (Weiye, A-003; Shenzhen
Weiye Measuring tool Company) at the end of
normal expiration to the nearest 0.1 cm. BMI was cal-
culated from their height and weight (kg/m2), waist-
to-height ratio (WHtR) was calculated as WC divided
by height. SFT were measured on the right side of the
body using Skinfold Caliper (Minjian, GMCS-PZQ;
Beijing Xindong Huateng Sports Instruments
Company, Limited) to the nearest 0.5 mm, at the two
sites: (i) triceps, halfway between the acromion pro-
cess and the olecranon process, and (ii) subscapular,
1.0 cm below the inferior angle of the scapula, at an
angle of 45 to the lateral side of the body. In each
participant, three measurements were taken, and the
middle value was recorded for one skinfold site.
Subscapular to triceps skinfold thickness ratio (STR),
an index of subcutaneous adipose tissue distribution
(truncal/peripheral), was calculated based on the
measurements at the two sites. Systolic blood pressure
(SBP) and diastolic blood pressure (DBP) were meas-
ured using a mercury sphygmomanometer after each
subject had rested for at least 15 min in a sitting pos-
ition. BP was measured twice on the right arm with
an appropriately sized cuff (covering 1/23/4 of the
length of the upper arm) and the average value was
recorded on the study form. DBP was defined via
Korotkoff Sound 5.
Definitions
The BMI cutoff points recommended by the
International Obesity Task Force (IOTF) were used to
define overweight and general obesity [13].
Abdominal obesity was defined as WHtR  0.5 [14].
Relatively high BP (RHBP) status was defined as SBP
and/or DBP  95th percentile for age and gender
according to the BP reference standards for Chinese
children and adolescents established in 2010 [15]. The
age- and sex-specific quartiles of STR were calculated
(Table 1), and all subjects were classified into four
groups (Q1, STR < 25th. Q2, 25th  STR < 50th. Q3,
50th  STR < 75th. Q4, STR  75th). Subjects in the
upper fourth (Q4) were defined as truncal distribu-
tion, and those in the lower fourth (Q1) were defined
as peripheral distribution.
Statistical analyses
Considering the BMI, WC, WHtR, SBP and DBP lev-
els of children change with age, Z-scores of BMI, WC,
WHtR, SBP and DBP were calculated based on the
distribution of the total sample, and comparisons
among the four groups were made by one-way
 BLOOD PRESSURE 3

ANOVA (post-hoc analyses by LSD test). Prevalence
rates of overweight, general obesity, abdominal obesity
and RHBP were determined, and comparisons among
the four groups were made by v2 test. All analyses
were performed with the statistical package SPSS 11.5.
Significance was defined at the 0.05 level.
Results
The characteristics of BMI, WC, WHtR, SBP and
DBP among different groups by STR categories are
presented in Table 2. In both boys and girls, statistical
significant differences in BMI, WC, WHtR, SBP and
DBP were observed among the four groups (p < 0.01).
With increasing quartiles of STR, subjects tended to
Downloaded by [Australian Catholic University] at 18:59 27 August 2017
3.04.9 mmHg for boys, and 3.75.4 Kg/m2,
9.214.3 cm, 3.24.9 mmHg and 2.83.6 mmHg for
girls.
The prevalence of overweight, obesity and RHBP in
different groups categorized by STR are shown in
Table 3. For both boys and girls, an increasing trend
was observed from the Q1 group to the Q4 group
(p < 0.01). For boys, the prevalence of overweight,
general obesity and abdominal obesity increased from
11.93, 1.97 and 5.62% in the Q1 group to 20.96, 16.02
and 29.28% in the Q4 group, respectively (p < 0.01);
and for girls, from 5.20, 0.55 and 1.73% in the Q1
group to 19.21, 6.08 and 14.84% in the Q4 group,
respectively (p < 0.01). Similarly, the prevalence of
RHBP increased with the STR, from 14.98% for boys

have higher BMI, WC, WHtR and BP levels. The and 12.79% for girls in the Q1 group to 25.49% for
comparisons of BMI, WC and BP levels in children boys and 20.76 for girls in the Q4 group (p < 0.01). In
and adolescents aged 717 with different patterns of a word, children and adolescents with truncal distri-
subcutaneous fat distribution are shown in Figures bution (STR  75th) had higher prevalence of over-
12. For both boys and girls, the mean values of BMI, weight, obesity and RHBP than their counterparts
WC, SBP and DBP were significantly higher in with peripheral distribution (STR < 25th).
truncal distribution group (STR  75th) than in
peripheral distribution group (STR < 25th) in all age Discussion
groups (p < 0.01), the range of differences being
4.36.8 Kg/m2, 12.919.1 cm, 3.34.1 mmHg and To the best of our knowledge, this is the first study
examining the patterns of subcutaneous fat distribu-
Table 1. The quartiles of subscapular to triceps ratio in boys tion and its association with obesity and elevated BP
and girls aged 717 years. among children and adolescents in Shandong, one of
Boys Girls the populous provinces in China. Based on a large
Age/years 25th 50th 75th 25th 50th 75th sample survey, we found that truncal pattern of sub-
7 0.65 0.80 0.97 0.61 0.78 0.97 cutaneous fat distribution is associated with obesity
8 0.67 0.83 1.00 0.62 0.79 1.00
9 0.67 0.83 1.00 0.64 0.81 1.00
and elevated BP.
10 0.69 0.88 1.02 0.67 0.86 1.00 BMI is commonly used to assess a child's weight
11 0.69 0.90 1.03 0.71 0.88 1.03
12 0.70 0.91 1.04 0.73 0.89 1.04
status but it does not provide information about the
13 0.78 0.96 1.14 0.74 0.90 1.07 distribution of body fat. It has been recognized that
14 0.81 1.00 1.18 0.76 0.92 1.09 the relationship between obesity and cardiovascular
15 0.88 1.02 1.21 0.78 0.94 1.12
16 0.89 1.06 1.27 0.79 0.95 1.13 risk factors depends not only on the amount of body
17 0.94 1.09 1.37 0.80 0.96 1.14 fat but also on its distribution [8,10]. A number of

Table 2. Comparisons of Z-score for BMI, WC, WHtR, SBP and DBP in different groups categorized by STR.
Gender Group n Z-BMI Z-WC Z-WHtR Z-SBP Z-DBP
Boys Q1 4914 0.24 0.73 0.26 0.73 0.28 0.74 0.11 0.95 0.12 0.94
Q2 4683 0.08 0.87a 0.07 0.89a 0.09 0.91a 0.04 0.98a 0.09 0.97
Q3 4721 0.06 1.05b 0.03 1.06b 0.01 1.08b 0.04 1.01b 0.06 1.01b
Q4 5068 0.26 1.19c 0.29 1.17c 0.27 1.18c 0.11 1.03c 0.16 0.98c
F 232.50, p < 0.01 F 273.83, p < 0.01 F 265.73, p < 0.01 F 47.73, p < 0.01 F 86.93, p < 0.01
Girls Q1 4904 0.30 0.76 0.30 0.74 0.31 0.75 0.12 0.98 0.13 0.97
Q2 4720 0.10 0.91a 0.08 0.89a 0.09 0.90a 0.06 0.97a 0.07 0.95a
Q3 4663 0.11 1.02b 0.06 1.06b 0.06 1.06b 0.05 1.01b 0.06 1.00b
Q4 5014 0.29 1.16c 0.32 1.15c 0.31 1.15c 0.13 1.02c 0.15 1.00c
F 333.07, p < 0.01 F 350.20, p < 0.01 F 353.19, p < 0.01 F 62.90, p < 0.01 F 78.78, p < 0.01
Data presented as mean SD. BMI, body mass index. WC, waist circumference. WHtR, waist-to-height ratio. SBP, systolic blood pressure. DBP, diastolic
blood pressure. STR, subscapular to triceps ratio. Q1, STR < 25th. Q2, 25th  STR < 50th. Q3, 50th  STR < 75th. Q4, STR  75th.
a
p < 0.01 compared with Q1 group.
b
p < 0.01 compared with Q2 group.
c
p < 0.01 compared with Q3 group.
 4 Y.-X. ZHANG ET AL.

26

24

22

BMI/ kg/m2 20

18

16 Q1-Boys
Q4-Boys
14 Q1-Girls
Q4-Girls
Age/ years
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12
7 8 9 10 11 12 13 14 15 16 17

90

85

80

75

70
WC/ cm

65

60
Q1-Boys
55
Q4-Boys
50 Q1-Girls
Q4-Girls
45
Age/ years
40
7 8 9 10 11 12 13 14 15 16 17
Figure 1. Mean values of BMI and WC in boys and girls with different patterns of fat distribution. (BMI, body mass index. WC,
waist circumference. STR, subscapular to triceps skinfold thickness ratio. Q1, STR < 25th. Q4, STR  75th).

different tools and methodologies have been devel-
oped to measure body composition, and SFT have
been shown to be closely correlated with total body
fatness [1619]. Subscapular and triceps skinfolds
were used because they are sites easy to locate and
measure. Furthermore, ratio based on the two skin-
folds (STR) has often been used as an index of the
distribution of subcutaneous fat between truncal and
peripheral depots, and has been proposed as a marker
of cardiovascular risk [10,20].
Epidemiological studies have illustrated convin-
cingly that fat distribution is associated with cardio-
vascular risk factors in both children and adults
[8,10,21]. Several studies in children and adolescents
have observed a significant relationship between car-
diovascular risk factors and STR, children and adoles-
cents with truncal obesity are at a substantially
increased risk for the development of multiple cardio-
vascular risk factors [22]. Tresaco et al. observed
a negative association between STR and HDL-
cholesterol levels in male adolescents [23]. A negative
association between STR and HDL cholesterol levels
has also been found among children and adolescents
aged 419 years in the Third National Health and
Nutrition Examination Survey (NHANES III) [24].
Misra et al. reported a high prevalence of insulin
 BLOOD PRESSURE 5

130

120 Boys

110

Blood pressure/ mmHg

Q1-SBP
100
Q4-SBP
Q1-DBP
90
Q4-DBP
80

70

60

Age/ years
50
Downloaded by [Australian Catholic University] at 18:59 27 August 2017

7 8 9 10 11 12 13 14 15 16 17

130

120
Girls

110
Blood pressure/ mmHg

100
Q1-SBP

90 Q4-SBP
Q1-DBP
80 Q4-DBP

70

60

Age/ years
50
7 8 9 10 11 12 13 14 15 16 17
Figure 2. Mean values of SBP and DBP in boys and girls with different patterns of fat distribution. (SBP, systolic blood pressure.
DBP, diastolic blood pressure. STR, subscapular to triceps skinfold thickness ratio. Q1, STR < 25th. Q4, STR  75th).

Table 3. Prevalence of overweight, general obesity, abdominal obesity and relatively high BP in different groups categorized by
STR.
Gender Group n Overweight General obesity Abdominal obesity Relatively high BP
Boys Q1 4914 11.93 (11.0212.84) 1.97 (1.582.36) 5.82 (5.176.47) 14.98 (13.9815.98)
Q2 4683 18.04 (16.9419.14)a 4.46 (3.875.05)a 12.13 (11.1913.07)a 17.32 (16.2418.40)a
Q3 4721 20.42 (19.2721.57)b 8.05 (7.278.83)b 18.00 (16.9019.10)b 22.52 (21.3323.71)b
Q4 5068 20.96 (19.8422.08) 16.02 (15.0117.03)c 29.28 (28.0330.53)c 25.49 (24.2926.69)c
x2172.46, p < 0.01 x2787.85, p < 0.01 x21083.34, p < 0.01 x2211.58, p < 0.01
Girls Q1 4904 5.20 (4.585.82) 0.55 (0.340.76) 1.73 (1.372.09) 12.79 (11.8613.72)
Q2 4720 9.68 (8.8410.52)a 1.55 (1.201.90)a 5.53 (4.886.18)a 13.26 (12.2914.23)
Q3 4663 14.88 (13.8615.90)b 3.26 (2.753.77)b 8.88 (8.069.70)b 18.12 (17.0119.23)b
Q4 5014 19.21 (18.1220.30)c 6.08 (5.426.74)c 14.84 (13.8615.82)c 20.76 (19.6421.88)c
x2510.62, p < 0.01 x2310.82, p < 0.01 x2638.31, p < 0.01 x2161.09, p < 0.01
Data presented as percentage (95% confidence interval). STR, subscapular to triceps ratio. Q1, STR < 25th. Q2, 25th  STR < 50th. Q3, 50th  STR < 75th.
Q4, STR  75th.
a
p < 0.017 compared with Q1 group.
b
p < 0.017 compared with Q2 group.
c
p < 0.017 compared with Q3 group.
 6 Y.-X. ZHANG ET AL.
resistance is associated with truncal body fat pattern-
ing in Indian children [25]. Therefore, several studies
suggested that fat distribution is a more important
independent correlate of cardiovascular risk factors
than percent body fat in children and adolescents
[21]. In this study, we found that obesity and elevated
BP is associated with the distributional pattern of sub-
cutaneous fat in children and adolescents, children
and adolescents with truncal fat distribution had
higher prevalence of obesity and elevated BP than
those with peripheral fat distribution. Together with
the above literatures, our results suggested that more
attention should be paid to monitoring of fat distribu-
tion among children and adolescents, public health
attention should not only focus on the amount of
Downloaded by [Australian Catholic University] at 18:59 27 August 2017
body fat, but also on the changes in distributional pat-
tern of body fat.
Childhood overweight and obesity has increased
dramatically during the past decades, both in develop-
ing and developed countries [1,2]. In the present
study, we found that the total prevalence of over-
weight and obesity were 17.83 and 7.73% for boys,
and 12.27 and 2.89% for girls by the IOTF BMI cut-
offs in the large sample. When WHtR was used to
diagnose abdominal obesity, we also found 16.44% of
boys and 7.79% of girls suffer from abdominal obes-
ity. These figures indicated a widespread epidemic
situation among children and adolescents in
Shandong China. Comprehensive strategies of inter-
vention should include periodical monitoring, educa-
tion on pattern of nutrition, physical exercises and
healthy dietary behavior, to achieve reasonable dietary
intake, increase physical activity, a change in seden-
tary lifestyles and corresponding behavioral
modifications.
The major strength of this study is that, based on
the data from a large population, it examines the pat-
terns of subcutaneous fat distribution and its associ-
ation with obesity and elevated BP among children
and adolescents. However, three limitations are noted.
Firstly, BP measurement at a single visit usually over-
estimates hypertension prevalence; however, the pur-
pose of using BP categories in the analysis was to
obtain a general idea of the extent of high BP in the
studied adolescents rather than to diagnose the pres-
ence of hypertension among them. Thus, in this
paper, we use the term relatively high BP rather than
high BP. Secondly, because of various restraints,
other biochemical indicators (e.g., blood lipids and
blood glucose) were not measured in the sample; an
in-depth factor analysis could not be carried out. We
hope that future studies will address this topic.
Thirdly, the absence of international and national STR
cut-offs for fat distribution was also a limitation, so
the definition for distributional pattern of subcutane-
ous fat in this study was relative and shortcoming was
inevitable.
In summary, this study demonstrated that obesity
and elevated BP is associated with the distributional
pattern of subcutaneous fat in children and adoles-
cents, children and adolescents with truncal fat distri-
bution had higher prevalence of obesity and elevated
BP than those with peripheral fat distribution.
Therefore, public health attention should not only
focus on the amount of body fat, but also on the
changes in distributional pattern of body fat.
Acknowledgements
We thank all the team members and all participants. Special
thanks to Mr. B Yu for providing access to the survey data.
Disclosure statement
There are no conflicts of interest on behalf of any of the
authors.
Funding
This study was supported by the Medical and Health
Program of Shandong, China (2014WS0376). Surveys on
students constitution and health are conducted under the
auspices of the department of education in Shandong
Province, China.
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