(Circulation. 1995;92:3249-3254.)
© 1995 American Heart Association, Inc.
Articles |
Effect of Lean Body Mass, Fat Mass, Blood Pressure, and Sexual Maturation on Left Ventricular Mass in Children and Adolescents
Statistical, Biological, and Clinical Significance
From the Division of Cardiology, Department of Pediatrics, University of Cincinnati (Ohio) College of Medicine and Children's Hospital Medical Center, Cincinnati, Ohio.
Correspondence to Stephen R. Daniels, MD, PhD, Division of Cardiology, Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229.
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Abstract |
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 Top Abstract IntroductionMethods Results Discussion References |
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Background Left ventricular hypertrophy has been established as an independent risk factor for the development of cardiovascular morbidity and mortality. It is clear that left ventricular mass increases during childhood and adolescence with body growth. The extent to which other factors, such as obesity, stage of sexual maturation, and level of blood pressure, determine left ventricular mass has been controversial.
Methods and Results The study was a cross-sectional evaluation of the relationship of left ventricular mass determined by echocardiography with lean body mass and fat mass determined by dual-energy x-ray absorptiometry, which is the most valid and reliable method for determination of body composition in children and adolescents. The relationship of left ventricular mass with the stage of sexual maturation and with systolic and diastolic blood pressure was also evaluated. Two hundred one subjects (105 boys, 96 girls; 103 white and 98 black) 6 to 17 years old were studied. Age (r=.72), height (r=.81), weight (r=.84), body surface area (r=.87), sexual maturation (r=.75), lean body mass (r=.86), fat mass (r=.54), systolic BP (r=.58), and diastolic BP (r=.48) were all univariate correlates of left ventricular mass. In a multiple regression analysis, only lean body mass, fat mass, and systolic blood pressure were statistically significant independent correlates of left ventricular mass. Lean body mass alone explained 75% of the variance of left ventricular mass, whereas fat mass and systolic blood pressure explained only 1.5% and 0.5% of the variance, respectively. Lean body mass was the strongest determinant of left ventricular mass in all four race-sex groups.
Conclusions This study provides an opportunity to separate the effects on left ventricular mass of lean body mass resulting from linear growth from those of fat mass resulting from obesity. Lean body mass, fat mass, and systolic blood pressure all have a statistically significant independent association with left ventricular mass, suggesting that all three play an important biological role in determining left ventricular mass. However, fat mass and systolic blood pressure have only a small impact on left ventricular mass. This indicates that fat mass and blood pressure would be expected to be of only minor clinical importance in determining left ventricular mass in normal children and adolescents.
Key Words: blood pressure • body mass • left ventricular mass
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Introduction |
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TopAbstractIntroductionMethods Results Discussion References |
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Left ventricular hypertrophy has been established as an independent risk factor for the development of cardiovascular morbidity and mortality.1 2 3 Therefore, understanding the determinants of left ventricular mass in children and adolescents has become increasingly important. It is clear that left ventricular mass increases during childhood and adolescence with body growth.4 It has also been suggested that other factors, such as ponderosity, blood pressure, and sexual maturation, may have an effect on left ventricular mass. However, the extent to which these other factors have an impact on left ventricular mass has been controversial. For example, some authors have suggested that obesity has a clinically important and potentially modifiable adverse effect on left ventricular mass,5 6 but others have argued that the impact of obesity above that of linear growth is minimal.7 One deficiency of previous research is that investigators have often used body mass index or ponderal index as a measure of obesity. However, body mass and ponderal indexes, which are functions of height and weight alone, incorporate elements of both lean body mass and obesity. Dual-energy x-ray absorptiometry (DEXA) provides a definitive method of accurately determining lean body mass and fat mass and allows investigation of their independent effects on left ventricular mass.8 9 10 11
The purpose of this investigation was to evaluate the effects of lean body mass, fat mass, blood pressure, and sexual maturation on left ventricular mass in children and adolescents. The goal was to determine whether these factors had a statistically significant independent effect on left ventricular mass as well as to judge whether the effect of these factors was likely to be of biological or clinical importance.
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Methods |
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TopAbstractIntroductionMethods Results Discussion References |
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Subjects
The subjects were 201 children and adolescents from 6 to 17 years old. Children and adolescents with abnormalities on physical examination or echocardiography were excluded from the study. Written informed consent was obtained from parents or legal guardians, and verbal assent was obtained from subjects
11 years old
before their participation in the study. This study was approved by the
Institutional Review Board of the Children's Hospital Medical
Center.
Anthropometric Measurements
Examination included measurement
of height; weight; and triceps,
subscapular, and suprailiac skinfold thicknesses. Body mass index was
calculated as weight/height2.
Dual Energy X-Ray Absorptiometry
DEXA is a relatively new
method of assessing body composition in
humans. This technology has the potential to provide information about
lean body mass as well as total and regional body fat. It uses two
x-ray beams that traverse the length of the body. The energy that
is collected by the external detector is attenuated by the bone and
soft tissue through which it has passed. The flux, or number of photons
measured per unit area, is corrected for soft tissue by a linear
two-dimensional interpolation, and the corrected values are summed
to estimate total body mineral content. Soft tissue is resolved by use
of mass attenuation coefficients from tissue equivalent standards for
fat and fat-free tissue. DEXA has been shown to provide accurate
and precise estimates of total body fat, bone mineral content, and
fat-free mass.8 9 10 11 DEXA
has been validated against the
hydrodensitometry method that has previously been established as the
most valid and reliable method for measurement of lean body
mass.8
Subjects in this study were scanned with a Hologic (QDR-1000/W) whole-body scanner. For data interpretation, body composition is divided into soft-tissue mass and bone mass. The soft-tissue mass can then be divided into lean body mass and fat mass.
Blood Pressure
Blood pressure was measured by auscultation
with mercury
sphygmomanometers.12 Systolic and
diastolic blood pressures were measured with an appropriate
size cuff in the right arm with the subjects seated, with feet on the
floor and arm at heart level. Three blood pressure measurements were
made, each separated from the next by at least 1 minute. The onset of
the fifth Korotkoff phase was used to determine diastolic
blood pressure. The average of the three determinations for
systolic and diastolic blood pressure was used in
the analysis. The staff received a standard 16-hour blood
pressure measurement training course and were certified according to a
previously established protocol.13
Sexual Maturation
Pubertal staging was determined by physical
assessment.
Examiners of boys were male and examiners of girls were female. For
boys, the maturation assessment included pubic hair stage as defined by
Marshall and Tanner14 and determination of testicular
volume by means of the Prader orchidometer. Pubertal staging was
defined by the criteria of Biro et al,15 combining those
two elements to produce a scale of 1 to 4. For girls, maturation
staging was performed with staging criteria developed by Garn and
Falkner that incorporate pubic hair and areolar development based on
Tanner staging principles,16 which were modified to make
them suitable for girls of all ethnic groups and body habitus. These
methods have been described by Morrison et al17 and result
in a scale of 1 to 3: 1, prepubertal; 2, pubertal but premenarcheal;
and 3, postmenarcheal.
Echocardiographic Measurements
Echocardiographic examination
of the left
ventricle was performed by standard techniques with subjects in a
supine position. Studies were performed using two-dimensional
guided M-mode echocardiograms with transducer frequencies appropriate
for body size. Measurements of the left ventricular
internal dimension, interventricular septal thickness,
and posterior wall thickness were made at end diastole
according to the criteria of the American Society of
Echocardiography.18 Left
ventricular mass was calculated from the equation reported
by Devereux et al19 20 derived for American Society
of
Echocardiography measurements and validated against
anatomic measurements.
Statistical Analysis
Descriptive statistics, including
mean±SD for continuous
variables and proportions for categorical variables, are
presented for age, sex, lean body mass, fat mass,
anthropometric characteristics, sexual maturation, blood pressure, and
echocardiographic measurements for the study cohort.
Pearson correlation coefficients were calculated to determine which
independent variables had a significant univariate
association with left ventricular mass. Stepwise linear
regression analysis was used to determine the independence of
correlates of left ventricular mass. Independent
variables were allowed to remain in the model if the regression
coefficient for that variable was significantly different from zero
even if the independent variable explained only a small portion of
the variance of left ventricular mass. Partial
R2 coefficients were used to determine the
amount of variance in left ventricular mass explained by
each independent variable. A value of P<.05 was used to
indicate statistical significance. Sex and racial differences in the
correlates of left ventricular mass were evaluated with
sex- and race-specific regression models. Because the sample size
was reduced in the race- and sex-specific models, a value of
P=.10 was used to indicate statistical significance in these
models.
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Results |
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TopAbstractIntroductionMethods Results Discussion References |
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Two hundred one subjects were included in the study, 105 boys and 96 girls; 103 subjects were white and 98 were black. The subjects ranged in age from 6 to 17 years. Summary statistics for age, anthropometric variables, blood pressure, and echocardiographic variables are presented in Table 1
. The distribution for stage of sexual
maturation was 15 (15%) stage 1, 41 (40%) stage II, 27 (26%) stage
III, and 19 (19%) stage IV for boys and 39 (44%) stage I, 18 (20%)
stage II, and 31 (35%) stage III for girls.
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Correlates of Left Ventricular Mass
The Pearson correlation
coefficients for the association of
various independent variables and left ventricular mass
are presented in Table 2. In general, the
correlations between independent variables and left
ventricular mass were similar by race and sex, so only the
overall correlations are reported.
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Multiple Regression Analysis
Multiple regression analysis was
used to determine the
independence of variables that explain the variance of left
ventricular mass. The stepwise regression analysis
is presented in Table 3. This analysis
demonstrates that lean body mass, fat mass, and systolic blood
pressure are significant independent correlates of left
ventricular mass. Sexual maturation was a significant
univariate correlate of left ventricular mass,
but it did not remain significant in the multivariable
analysis. The variance of left ventricular mass
explained by the model is 77%. Each of the regression coefficients is
positive, indicating that increased lean body mass, fat mass, and
systolic blood pressure are all associated with increased left
ventricular mass. Table 4 presents the
percent of variance explained by each of the variables as reflected
in the partial R2. These results demonstrate
that lean body mass explains most of the variance of left
ventricular mass. Although fat mass and systolic
blood pressure are statistically significant correlates of left
ventricular mass, they explain only a small portion of the
variance. Fat mass and systolic blood pressure may have
biological significance in determining left ventricular
mass in children and adolescents; however, it is unlikely that they
have a clinically important impact on left ventricular
mass. For example, based on the regression model, an increase in fat
mass of 10 kg would result in an increase in left
ventricular mass of only 5 g; an increase in
systolic blood pressure of 10 mm Hg would result in only a
2.6-g increase in left ventricular mass. In contrast, an
increase in lean body mass of 10 kg would result in a 20.2-g increase
in left ventricular mass.
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The significant independent variables for
explaining the variance
of left ventricular mass by race and sex are
presented in Table 5. Although there are some
minor differences by race and sex, lean body mass is clearly the most
important correlate of left ventricular mass for whites and
blacks, boys and girls. Fat mass is also a significant correlate in
each of the models except for whites, in whom it did not reach
statistical significance (P<.10). The differences by race
and sex must be interpreted cautiously because of decreased sample size
for those comparisons.
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Discussion |
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TopAbstractIntroductionMethods Results Discussion References |
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The determinants of left ventricular mass in children and adolescents have been controversial, and the relative roles of lean body mass, ponderosity, and blood pressure have been debated. The present study provides a more definitive answer to this question because of the use of DEXA, which is the most valid, reliable, and clinically useful method currently available for measurement of body composition in children and adolescents. This allows for separation of the influences of lean body mass and fat mass on left ventricular mass.
In this study, we found that lean body mass and fat mass were both statistically significant correlates of left ventricular mass. However, lean body mass is a much stronger predictor of left ventricular mass than is fat mass. These results are consistent with the findings of Goble et al,7 who reported that body weight but not ponderosity is a strong predictor of left ventricular mass. Goble et al also reported that body fat as measured by suprailiac skinfold thickness was inversely associated with left ventricular mass. However, this finding may be a statistical artifact, because the major variable in their model, weight, includes both elements of lean body mass and fat mass. Thus, it was not possible for them to completely separate their effects. Urbina et al6 reported that the major factor influencing left ventricular mass in the Bogalusa Heart Study was linear growth as determined by height. In addition, they found that weight and measures of ponderosity were significant determinants of left ventricular mass. They suggested that obesity was a clinically important and potentially modifiable determinant of left ventricular mass. However, they did not report the partial correlation coefficients to determine the relative impact of linear growth and obesity. In the Muscatine Study, Malcolm et al5 found significant correlations between left ventricular mass and height, weight, and Quetelet index. In a more recent investigation, investigators from the Muscatine Study used bioelectric impedance analysis to attempt to separate the effects of fat-free body mass in a population of white children 8 to 12 years old.21 They found that 72% of the variability in left ventricular mass was explained by fat-free mass, sum of skinfolds, and peak exercise systolic blood pressure. They reported that fat-free mass explained 50% and sum of skinfolds 15% of the variance of left ventricular mass in boys. In girls, fat-free mass explained 62% of the variance of left ventricular mass, and sum of skinfolds was not an independent predictor of left ventricular mass. In our study, which used DEXA, a more definitive measurement of lean body and fat mass, we found that lean body mass explained 75% of the variance of left ventricular mass overall. We also found that fat mass was a statistically significant but minor predictor of left ventricular mass in both boys and girls.
The results of this study indicate that fat mass is a relatively weak
correlate and independently explains only 
1.5% of the variance of
left ventricular mass index. This suggests that fat mass
has a relatively minor clinical role in determining left
ventricular mass. This is consistent with the
findings of Verhaaren et al,22 who reported that when
using the bivariate common-factor model in a twin study, they found
that specific environmental influences common to weight and left
ventricular mass account for <3% of the total variability
in white children of both sexes. They also found that >90% of the
correlation between weight and left ventricular mass was
explained by genetic effects.
Although we have separated the impact of lean body mass and fat mass on left ventricular mass, it is important to remember that lean body mass may also be increased in childhood obesity.23 The mechanism of the increase in lean body mass associated with obesity is poorly understood, but it may be responsible for some of the pathological effects of obesity, such as hypertension24 or left ventricular hypertrophy. The effects of weight loss on lean body mass in obese individuals is also poorly understood. Longitudinal studies will be necessary to better understand these relationships.
The role of sexual maturation in determining left ventricular mass has not been studied extensively. In the Muscatine Study, Janz et al21 found that there was a univariate association between testosterone levels and left ventricular mass in both boys (r=.35) and girls (r=.55). Tanner staging was also performed in that study, but the correlation with left ventricular mass is not reported. In their multivariable analysis, testosterone level was not a significant independent correlate of left ventricular mass for either boys or girls. Our results confirm these findings. We did not find a significant independent relationship between sexual maturation and left ventricular mass. This suggests that the impact of sexual maturation on left ventricular mass operates through changes in body size. This is consistent with the results reported by Verhaaren et al22 in the Medical College of Virginia Twin Study. However, a longitudinal study with better biochemical indexes of sexual maturation may be needed to provide a definitive answer to this question.
The role of blood pressure in determining left ventricular mass has also been debated. The relationship is biologically plausible in that the increased afterload associated with elevation of blood pressure presents a stimulus for hypertrophy to reduce the peak systolic wall stress of the left ventricle. We previously reported a significant independent association between measures of afterload and left ventricular mass index in young patients with hypertension.25 However, studies have not always documented a relationship between resting blood pressure and left ventricular mass. For example, we reported that systolic blood pressure at maximum bicycle exercise was a correlate of left ventricular mass index, but resting blood pressure was not, in a population of children and adolescents with essential hypertension.26 Janz et al21 reported similar findings in a population of normal children from the Muscatine Study. Conversely, Goble et al7 found that resting systolic blood pressure was a determinant of left ventricular mass in boys but not in girls. Malcolm et al5 found that resting systolic and diastolic blood pressures were independent predictors of left ventricular mass in a large group of 904 children 6 to 16 years old in the Muscatine Study. They also found that systolic blood pressure was a stronger predictor of left ventricular mass than was diastolic blood pressure. In the Bogalusa Heart Study, Urbina et al6 found univariate associations between systolic and diastolic blood pressures and left ventricular mass, but they did not find that blood pressure was significant in a multivariable analysis of follow-up left ventricular mass after anthropometric variables were included in the regression model.
We found a statistically significant but weak independent association between systolic blood pressure and left ventricular mass after lean body mass and fat mass were included in the overall multiple regression model. This suggests that blood pressure plays a biologically important role in determining left ventricular mass and that the role of blood pressure is additive to that of obesity. This is similar to the findings reported by deSimone et al27 in adults. However, the weakness of the association suggests that resting systolic blood pressure is unlikely to play a clinically significant role in determining left ventricular mass in normal children and adolescents.
We found some differences in the role of blood pressure by race and sex. Diastolic blood pressure was a significant determinant of left ventricular mass in white but not black subjects. Systolic blood pressure was included in the multiple regression model for girls but not for boys. However, these results must be interpreted with caution, because resting blood pressure is only a weak determinant of left ventricular mass and the sample size is reduced in race- and sex-specific analyses. Ambulatory blood pressure monitoring and the response of blood pressure to exercise were not included in the present study but may provide improved explanation of the variance of left ventricular mass.
Conclusions
Left ventricular hypertrophy increases the
risk of cardiovascular morbidity and mortality in
adults.1 2 3 However, the factors leading
to the development
of left ventricular hypertrophy are not well
established. The early developmental stages in children and adolescents
are poorly understood. In any epidemiological investigation, it is
important to determine statistical significance to evaluate the role of
chance in the observed results. It is also important to assess the
likely biological and clinical importance of results that are
statistically significant.28 This study provides an
opportunity to separate the effects of lean body mass and fat mass on
left ventricular mass in a definitive way. It is clear from
these results that lean body mass, fat mass, and to a lesser extent,
blood pressure all have a statistically significant independent
association with left ventricular mass in normal children
and adolescents. Sexual maturation apparently does not have a
significant association with left ventricular mass
independent of body size. This indicates that linear growth, obesity,
and blood pressure all are likely to play an important biological role
in determining left ventricular mass. However, fat mass and
systolic blood pressure appear to have only a small impact on
left ventricular mass after the effect of lean body mass is
accounted for. This suggests that fat mass and blood pressure are
likely to be of only minor clinical importance in determining left
ventricular mass in normal children and adolescents.
Obesity and blood pressure elevation represent two potentially
modifiable factors that affect left ventricular mass.
However, preventive measures directed at modifying obesity and blood
pressure may have only a limited impact on modifying left
ventricular mass in young people.
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Acknowledgments |
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This study was supported in part by grant R01-HL-34698 from the National Heart, Lung, and Blood Institute and US Public Service Grant RR-08084 from the National Center for Research Resources, General Clinical Research Centers Program, National Institutes of Health.
Received June 27, 1995; revision received August 16, 1995; accepted September 25, 1995.
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References |
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TopAbstractIntroductionMethods Results Discussion References |
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E. Lurbe, I. Torro, V. Alvarez, T. Nawrot, R. Paya, J. Redon, and J. A. Staessen Prevalence, Persistence, and Clinical Significance of Masked Hypertension in Youth Hypertension, April 1, 2005; 45(4): 493 - 498. [Abstract] [Full Text] [PDF]
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National High Blood Pressure Education Program Wor The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents Pediatrics, August 1, 2004; 114(2/S2): 555 - 576. [Full Text] [PDF]
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J. M. Sorof, J. Turner, D. S. Martin, K. Garcia, Z. Garami, A. V. Alexandrov, F. Wan, and R. J. Portman Cardiovascular Risk Factors and Sequelae in Hypertensive Children Identified by Referral Versus School-Based Screening Hypertension, February 1, 2004; 43(2): 214 - 218. [Abstract] [Full Text] [PDF]
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J. Lindenfeld, J. K. Ghali, H. J. Krause-Steinrauf, S. Khan, K. Adams Jr, S. Goldman, M. A. Peberdy, C. Yancy, S. Thaneemit-Chen, R. L. Larsen, et al. Hormone replacement therapy is associated with improved survival in women with advanced heart failure J. Am. Coll. Cardiol., October 1, 2003; 42(7): 1238 - 1245. [Abstract] [Full Text] [PDF]
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J. M. Sorof, A. V. Alexandrov, G. Cardwell, and R. J. Portman Carotid Artery Intimal-Medial Thickness and Left Ventricular Hypertrophy in Children With Elevated Blood Pressure Pediatrics, January 1, 2003; 111(1): 61 - 66. [Abstract] [Full Text] [PDF]
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J. Sorof and S. Daniels Obesity Hypertension in Children: A Problem of Epidemic Proportions Hypertension, October 1, 2002; 40(4): 441 - 447. [Abstract] [Full Text] [PDF]
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J. M. Gardin, D. Brunner, P. J. Schreiner, X. Xie, C. L. Reid, K. Ruth, D. E. Bild, and S. S. Gidding Demographics and correlates of five-year change in echocardiographic left ventricular mass in young black and white adult men and women: the Coronary Artery Risk Development in Young Adults (CARDIA) Study J. Am. Coll. Cardiol., August 7, 2002; 40(3): 529 - 535. [Abstract] [Full Text] [PDF]
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B. M. Mitchell, B. Gutin, G. Kapuku, P. Barbeau, M. C. Humphries, S. Owens, S. Vemulapalli, and J. Allison Left Ventricular Structure and Function in Obese Adolescents: Relations to Cardiovascular Fitness, Percent Body Fat, and Visceral Adiposity, and Effects of Physical Training Pediatrics, May 1, 2002; 109(5): e73 - 73. [Abstract] [Full Text] [PDF]
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C. Dekkers, F. A. Treiber, G. Kapuku, E. J.C.G. van den Oord, and H. Snieder Growth of Left Ventricular Mass in African American and European American Youth Hypertension, May 1, 2002; 39(5): 943 - 951. [Abstract] [Full Text] [PDF]
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J. M. Sorof, G. Cardwell, K. Franco, and R. J. Portman Ambulatory Blood Pressure and Left Ventricular Mass Index in Hypertensive Children Hypertension, April 1, 2002; 39(4): 903 - 908. [Abstract] [Full Text] [PDF]
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G. de Simone, F. Pasanisi, and F. Contaldo Link of Nonhemodynamic Factors to Hemodynamic Determinants of Left Ventricular Hypertrophy Hypertension, July 1, 2001; 38(1): 13 - 18. [Abstract] [Full Text] [PDF]
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C. Garner, E. Lecomte, S. Visvikis, E. Abergel, M. Lathrop, and F. Soubrier Genetic and Environmental Influences on Left Ventricular Mass : A Family Study Hypertension, November 1, 2000; 36(5): 740 - 746. [Abstract] [Full Text] [PDF]
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M. Shimoyama, D. Hayashi, Y. Zou, E. Takimoto, M. Mizukami, K. Monzen, S. Kudoh, Y. Hiroi, Y. Yazaki, R. Nagai, et al. Calcineurin Inhibitor Attenuates the Development and Induces the Regression of Cardiac Hypertrophy in Rats With Salt-Sensitive Hypertension Circulation, October 17, 2000; 102(16): 1996 - 2004. [Abstract] [Full Text] [PDF]
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B. Kuch, H.-W. Hense, B. Gneiting, A. Doring, M. Muscholl, U. Brockel, and H. Schunkert Body Composition and Prevalence of Left Ventricular Hypertrophy Circulation, July 25, 2000; 102(4): 405 - 410. [Abstract] [Full Text] [PDF]
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B. H. Lorell and B. A. Carabello Left Ventricular Hypertrophy : Pathogenesis, Detection, and Prognosis Circulation, July 25, 2000; 102(4): 470 - 479. [Full Text] [PDF]
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K. F. Janz, J. D. Dawson, and L. T. Mahoney Predicting Heart Growth During Puberty: The Muscatine Study Pediatrics, May 1, 2000; 105(5): 63e - 63. [Abstract] [Full Text]
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G. K. Kapuku, F. A. Treiber, H. C. Davis, G. A. Harshfield, B. B. Cook, and G. A. Mensah Hemodynamic Function at Rest, During Acute Stress, and in the Field : Predictors of Cardiac Structure and Function 2 Years Later in Youth Hypertension, November 1, 1999; 34(5): 1026 - 1031. [Abstract] [Full Text] [PDF]
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S. R. Daniels, J. A. Morrison, D. L. Sprecher, P. Khoury, and T. R. Kimball Association of Body Fat Distribution and Cardiovascular Risk Factors in Children and Adolescents Circulation, February 2, 1999; 99(4): 541 - 545. [Abstract] [Full Text] [PDF]
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J. N. Bella, R. B. Devereux, M. J. Roman, M. J. O'Grady, T. K. Welty, E. T. Lee, R. R. Fabsitz, B. V. Howard, and f. t. S. H. S. Investigators Relations of Left Ventricular Mass to Fat-Free and Adipose Body Mass : The Strong Heart Study Circulation, December 8, 1998; 98(23): 2538 - 2544. [Abstract] [Full Text] [PDF]
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C.-H. Chen, C.-T. Ting, S.-J. Lin, T.-L. Hsu, S.-J. Ho, P. Chou, M.-S. Chang, F. O'Connor, H. Spurgeon, E. Lakatta, et al. Which Arterial and Cardiac Parameters Best Predict Left Ventricular Mass? Circulation, August 4, 1998; 98(5): 422 - 428. [Abstract] [Full Text] [PDF]
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H.-W. Hense, B. Gneiting, M. Muscholl, U. Broeckel, B. Kuch, A. Doering, G.u. A. J. Riegger, and H. Schunkert The associations of body size and body composition with left ventricular mass: impacts for indexation in adults J. Am. Coll. Cardiol., August 1, 1998; 32(2): 451 - 457. [Abstract] [Full Text] [PDF]
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S. S. Gidding Clinical and Epidemiological Significance of Left Ventricular Mass Assessed in Children and Adolescents Circulation, May 19, 1998; 97(19): 1893 - 1894. [Full Text] [PDF]
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S. R. Daniels, J. M. H. Loggie, P. Khoury, and T. R. Kimball Left Ventricular Geometry and Severe Left Ventricular Hypertrophy in Children and Adolescents With Essential Hypertension Circulation, May 19, 1998; 97(19): 1907 - 1911. [Abstract] [Full Text] [PDF]
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A. M. Batterham and K. P. George Modeling the influence of body size and composition on M-mode echocardiographic dimensions Am J Physiol Heart Circ Physiol, February 1, 1998; 274(2): H701 - H708. [Abstract] [Full Text] [PDF]
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G. de Simone, G. F. Mureddu, R. Greco, L. Scalfi, A. Esposito Del Puente, A. Franzese, F. Contaldo, and R. B. Devereux Relations of Left Ventricular Geometry and Function to Body Composition in Children With High Casual Blood Pressure Hypertension, September 1, 1997; 30(3): 377 - 382. [Abstract] [Full Text]
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J. M. Gardin, A. Arnold, J. S. Gottdiener, N. D. Wong, L. P. Fried, H. S. Klopfenstein, D. H. O'Leary, R. Tracy, and R. Kronmal Left Ventricular Mass in the Elderly : The Cardiovascular Health Study Hypertension, May 1, 1997; 29(5): 1095 - 1103. [Abstract] [Full Text]
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G. de Simone, R. B. Devereux, S. R. Daniels, G. Mureddu, M. J. Roman, T. R. Kimball, R. Greco, S. Witt, and F. Contaldo Stroke Volume and Cardiac Output in Normotensive Children and Adults : Assessment of Relations With Body Size and Impact of Overweight Circulation, April 1, 1997; 95(7): 1837 - 1843. [Abstract] [Full Text]
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W. Group, S. S. Gidding, R. L. Leibel, S. Daniels, M. Rosenbaum, L. Van Horn, and G. R. Marx Understanding Obesity in Youth: A Statement for Healthcare Professionals From the Committee on Atherosclerosis and Hypertension in the Young of the Council on Cardiovascular Disease in the Young and the Nutrition Committee, American Heart Association Circulation, December 15, 1996; 94(12): 3383 - 3387. [Full Text]
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R. M. Schieken Large Hearts in Children : Biology or Disease? Circulation, December 1, 1995; 92(11): 3156 - 3157. [Full Text]
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