Research Article: Left ventricular mass is underestimated in overweight children because of incorrect body size variable chosen for normalization

Date Published: May 29, 2019

Publisher: Public Library of Science

Author(s): Hubert Krysztofiak, Marcel Młyńczak, Łukasz A. Małek, Andrzej Folga, Wojciech Braksator, Yvonne Böttcher.


Left ventricular mass normalization for body size is recommended, but a question remains: what is the best body size variable for this normalization—body surface area, height or lean body mass computed based on a predictive equation? Since body surface area and computed lean body mass are derivatives of body mass, normalizing for them may result in underestimation of left ventricular mass in overweight children. The aim of this study is to indicate which of the body size variables normalize left ventricular mass without underestimating it in overweight children.

Left ventricular mass assessed by echocardiography, height and body mass were collected for 464 healthy boys, 5–18 years old. Lean body mass and body surface area were calculated. Left ventricular mass z-scores computed based on reference data, developed for height, body surface area and lean body mass, were compared between overweight and non-overweight children. The next step was a comparison of paired samples of expected left ventricular mass, estimated for each normalizing variable based on two allometric equations—the first developed for overweight children, the second for children of normal body mass.

The mean of left ventricular mass z-scores is higher in overweight children compared to non-overweight children for normative data based on height (0.36 vs. 0.00) and lower for normative data based on body surface area (-0.64 vs. 0.00). Left ventricular mass estimated normalizing for height, based on the equation for overweight children, is higher in overweight children (128.12 vs. 118.40); however, masses estimated normalizing for body surface area and lean body mass, based on equations for overweight children, are lower in overweight children (109.71 vs. 122.08 and 118.46 vs. 120.56, respectively).

Normalization for body surface area and for computed lean body mass, but not for height, underestimates left ventricular mass in overweight children.

Partial Text

In children, as the body grows with age, the size of the heart also increases. Body size is a major determinant of cardiac size. Among different body size variables, lean body mass (LBM) seems to be the strongest predictor of the heart chamber size and wall thickness [1–3]. However, fat mass of the body, though not as strong a determinant of cardiac size as LBM, also has biological and clinical significance [1,2]. Obese children have increased left ventricular mass (LVM) compared to their lean peers, independently of other pathological determinants such as, e.g., hypertension [4,5], and overweight and obesity are common problems in children and adolescents [6]. The problem of excess body mass is also observed in young athletes [7,8], in whom regular physical activity is a strong determinant of left ventricular hypertrophy (LVH). In overweight or obese athletes, an effect of adiposity may be partially responsible for LVH [9].

The results of this study show that, for normalization of left ventricular mass for body size, among commonly used scaling variables, like BSA, computed LBM and height, only height allows for reliable evaluation of LVM in children and adolescents. Left ventricular mass normalized for height is not underestimated in overweight and obese children. This is because height as a scaling variable is free of the bias related to body mass index. In turn, LVM normalization for BSA gives misleading results, because normalized LVM is lower in overweight children compared to their lean peers. A similar effect is observed for LVM normalized for computed LBM.

We conducted an analysis, which has shown that when BSA or equation-based LBM are used for normalization of LVM, the normalized LVM is underestimated in overweight children. This is because these body size variables are derivatives of body mass and introduce an error to the normalized LVM, referred to as bias related to BMI. This analysis has also indicated that only height-based normalization of LVM is free of the BMI bias. Left ventricular mass normalized for height shows a correct pattern of higher normalized LVM in overweight children compared to children of normal body mass. A key practical message from this study is that height should be a body size variable of the first choice for cardiac size normalization.




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