摘要
目的
对13~19岁超重与正常体重青少年进行双能X线吸收法（DXA）骨密度和身体成分测量，分别比较其骨密度、身体成分和股骨近端骨强度指标的差异，探讨超重对青少年骨密度及股骨近端骨强度的影响。
方法
13~19岁健康男女青少年共139例，根据“中国学龄儿童青少年超重和肥胖筛查体重指数值分类标准”将其分为超重组(n=72，女29例，男43例)和正常体重组(n=67，女40例，男27例)，分别进行DXA骨密度（全身骨、腰椎L1-L4、股骨颈和全髋）、全身身体成分[全身骨量（WBBMC），lean mass（LM）和fat mass（FM)］测量，并采用髋关节强度分析（HSA）系统分析股骨近端截面惯性矩（CSMI）、截面面积（CSA）和截面模量（Z）等骨强度参数指标，分别比较不同性别青少年超重组与正常体重组骨密度及股骨近端骨强度的差异。
结果
1、超重男性和女性青少年的体重、体重指数（BMI）、身体成分参数（FM、LM、FM百分比）、WBBMC和BMD（全身骨、腰椎L1-L4、股骨颈和全髋）均高于正常体重组（P＜0.001）。经体重、BMI、FM和LM校正后，男女青少年超重组和正常体重组之间的WBBMC和BMD（全身、腰椎L1-L4、股骨颈和全髋）均无统计学差异（P＞0.05）。女性青少年的WBBMC和WBBMD与LM和FM呈正相关（r=0.533~0.784， P＜0.001），而男性青少年的WBBMC和WBBMD仅与LM呈正相关（r=0.438~0.699，P＜0.05），与FM无明显相关性。
2、超重男女青少年的骨强度参数（CSA、CSMI和Z）均高于正常体重组（P＜0.05）；在进行体重、FM和LM较正后，超重女性青少年的骨强度参数（CSA、CSMI和Z）无统计学差异（P＞0.05），而男性经体重和LM较正后，其骨强度参数（CSA、CSMI和Z）无统计学差异（P＞0.05），而经FM校正后则有显著性差异（P＜0.05）。女性青少年骨强度参数（CSMI、CSA和Z）与LM和FM呈正相关（r=0.562~0.735，P＜0.05），而男性青少年骨强度参数（CSMI、CSA和Z）与LM呈正相关（r=0.673~0.729，P＜0.05），与FM无明显相关性。
结论
超重男女青少年的全身骨、腰椎和股骨近端骨密度高于正常体重组；超重男女青少年的股骨近端骨强度较高，可能与其对高LM产生动态负荷适应有关。
Objective
The aim of this study was to determine the influence of being overweight on bone mineraldensity(BMD)，and to compare hip bone strength indices in overweight adolescents andgender-matched normal weight controls using hip structural analysis (HSA).
Methods
This study included72overweight adolescents (29girls,43boys) and67gender-matchednormal weight controls (40girls,27boys). Whole body bone mineral area(WBBMA), wholebody bone mineral content (WBBMC)，whole body (WB)BMD, femoral neck (FN) BMD, totalhip(TH)BMD, lumbar spine (L1-L4)BMD and body composition (lean mass and fat mass) wereassessed by dual-energy X-ray absorptiometry (DXA). DXA HSA was performed using LunarenCORE, version10.5software. Structural parameters derived by HSA were the bonecross-sectional area (CSA)，the cross-sectional moment of inertia (CSMI) and the sectionmodulus (Z).
Result
①DXA measurements of weight, body mass index (BMI), LM, FM, FM%, WBBMC andBMD (WB, L1-L4, TH and FN) were higher in overweight adolescents compared togender-matched control（sP＜0.001）. After adjusting for weight, BMI, lean mass, fat mass, thesedifferences disappeared. Lean mass and fat mass were positively correlated to WBBMC andWBBMD for adolescent girls（r=0.533~0.784, P＜0.001）. Lean mass was positively correlatedto WBBMC and WBBMD（r=0.438~0.699, P＜0.05）, but fat mass was not related to WBBMCand WBBMD for adolescent boys.②CSA, CSMI, and Z of femoral neck were higher inoverweight adolescents compared to controls (P＜0.05). After adjustment for either body weightor lean mass, using a one-way analysis of covariance, there were no differences between the twogroups regarding the HSA variables (CSA, CSMI and Z). After adjusting for fat mass,overweight boys displayed higher values of CSA, CSMI and Z in comparison to controls (P＜ 0.05), but there were not signicant differences between overweight girls and controls. Lean massand fat mass were all positively correlated with all HSA parameters (CSMI, CSA and Z) foradolescent girls（r=0.562~0.735, P＜0.05）. Lean mass was positively correlated with all HSAparameters (CSMI, CSA and Z)（r=0.673~0.729, P＜0.05）, but fat mass was not positivelyrelated with all HSA parameters (CSMI, CSA and Z) for adolescent boys.
Conclusion
Overweight adolescents do have higher BMD when compared with controls. Overweightadolescents have greater indices of proximal femur bone geometry in comparison to controls atthe femoral neck. Proximal femur bone geometric strength in overweight adolescents wasappropriately adapted to lean mass.
引文
[1] Ebbeling CB， Pawlak DB， Ludwig DS. Childhood obesity public-health crisis，commonsense cure[J]. Lancet，2002，360(9331)：473-482.
[2] O'Brien PE，Dixon JB.The extent of the problem of obesity[J]. Am J Surg.2002，184(6B)：4S-8S.
[3]中国学生营养与健康促进会.《关注儿童肥胖，远离慢性疾病》——中国儿童少年营养与健康报告蓝皮书对外发布[J].中国火炬，2009，8：35-35.
[4] Denen ME，Hennessey JV，Markert RJ. Outpatient evaluation of obesity in adults andchildren： A review of the performance of internal medicine pediatrics residents [J].JGenet Intern Med，1993，8(5)：268-270.
[5]杜松明，马冠生.儿童青少年肥胖评价标准的研究进展[J].国外医学卫生学分册，2006，33(5)：261-265.
[6] Bellizzi MC，Dietz WH. Workshop on childhood obesity：summary of the discussion [J].Am J Clin Nutr，1999，70(Suppl)：173S-175S.
[7] Must A，Dallal GE，Dietz WH. Reference data for obesity：85th and95th percentiles ofbody mass index (wt/ht2) and triceps skinfold thickness [J]. Am J Clin Nutr，1991，53(4)：839-846.
[8] Cole TJ，Bellizzi MC，Flegal KM，et al. Establishing a standard definition for childoverweight and obesity worldwide：international survey[J].BMJ，2003，320(7244)：1240-1243.
[9] Wang J，Thornton JC，Russell M，et al. Asians have lower body mass index (BMI) buthigher percent body fat than do whites：comparisons of anthropometric measurements[J].Am J Clin Nutr，1994，60(1)：23-28.
[10] Deurenberg P，Deurenberg-Yap M，Foo LF，et al. Differences in body compositionbetween Singapore Chinese，Beijing Chinese and Dutch children[J].Eur J Clin Nutr，2003，57(3)：405-409.
[11]中国肥胖问题工作组.中国学龄儿童青少年超重、肥胖筛查体重指数值分类标准[J]..中华流行病学杂志，2004，25(2)：97-102
[12]中国肥胖问题工作组数据汇总分析协作组.我国成人体重指数和腰围对相关疾病危险因素异常的预测价值：适宜体重指数和腰围切点的研究[J].中华流行病学杂志，2002，23(1)：5-10.
[13]王文娟，王克安，陈春明，等.北京地区儿童青少年体重指数与血压关系的研究[J].中华流行病学杂志，2004，25(2)：109-112.
[14] Ma GS，Li YP，Hu XQ，et al. Report on children obesity in china (2) verification of BMIclassification reference for overweight and obesity for Chinese children and adolescent [J].Biomed Environ Sci，2006，19(1)：1-7.
[15] Buckwalter JA，Glimcher MJ，Cooper RR，et al. Bone biology II： Formation，form，modeling，remodeling，and regulation of cell function[J]. Instr Course Lect，1996，45：387-399.
[16] Steven L，Teitelbaum. Bone Resorption by Osteoclasts [J]. Science，2000，289(5484)：1504-1508.
[17] Trotter M，Hixon BB. Sequential changes in weight，density，and percentage ash weightof human skeletons from an early fetal period through old age[J]. Anat Rec，1974，179(1)：1-18.
[18] Bailey DA，Martin A，McKay H，et al. Calcium accretion in girls and boys duringpuberty：A longitudinal analysis [J]. J Bone Miner Res，2000，15(11)：2245-2250.
[19] Fournier P，Rizzoli R，Slosman D，et al.Asynchrony between the rates of standing heigtgain and bone mass accumulation during puberty [J]. Osteoporosis Int，1997，7(6)：525-532.
[20] Bailey DA，McKay HA，Minwald RL，et al. A six-year longitudinal study of therelationship of physical activity to bone mineral accrual in growing children：TheUniversity of Saskatchewan Bone Mineral Accrual Study [J]. J Bone Miner Res，1999，14(10)：1672-1679.
[21] EFFO and NOF1997. Who are candidates for prevention and treatment for osteoporosis[J]? Osteoporos Int，1997，7(1)：1-6.
[22] Melton LJ3rd，Gabriel SE，Crowson CS，et al. Cost-equivalence of different osteoporoticfractures [J]. Osteoporos Int，2003，14(5)：383-388.
[23] Lewiecki EM，BaimS，Siris ES.Osteoporosis care at risk in the United States [J].Osteoporos Int，2008，19(11)：1505-1509.
[24] Riggs BL，Melton LJ3rd. The worldwide problem of osteoporosis： insights afforded byepidemiology[J]. Bone，1995，17(5Suppl)：505S-511S.
[25] Randell A，Sambrook PN，Nguyen TV，et al. Direct clinical and welfare costs ofosteoporotic fractures in elderly men and women [J]. Osteoporos Int1995，5(6)：427-432.
[26] Kanis JA，Johnell O，De Laet C，et al. A meta-analysis of previous fracture andsubsequent fracture risk [J]. Bone，2004，35（2）：375-382.
[27] Consensus Development Conference. Prophylaxis and treatment of osteoporosis [J].Am J Med，1991，90(1)：107-110.
[28] NIH Consensus Development Panel. Osteoporosis prevention，diagnosis，and therapy.JAMA，2001，285(6)：785-795.
[29] Cheng JC，Shen WY. Limb fracture pattern in different pediatric age groups： A study of3350children [J]. J Orthoped Trauma，1993，7(1)：15-22.
[30] Landin LA. Fracture patterns in children [J]. Acta Orthop Scan，1983，54(suppl202)：1-109.
[31] Khosla S，Melton LJ III，Dekutoski MB，et al. Incidence of childhood distal forearmfractures over30years：A population-based study [J]. JAMA，2003，290(11)：1479-1485.
[32] Bengner U，Johnell O. Increasing incidence of forearm fractures. A comparison ofepidemiologic patterns25years apart[J].Acta Orthopaedica Scandinavia，1985，56(2)：158-160.
[33] Sherker S，Ozanne-Smith J. Are current playground safety standards adequate forpreventing arm fractures [J]? MJA，2004，180(11)：562-565.
[34] Hagino H，Yamamoto K，Ohshiro H，et al. Increasing incidence of distal radius fracturesin Japanese children and adolescents [J]. J Orthopaedic Science，2000，5(4)：356-360.
[35] Goulding A，Cannan R，Williams SM，et al. Bone mineral density in girls with forearmfractures [J]. J Bone Miner Res，1998，13(1)：143-148.
[36] Goulding A，Grant AM，Williams SM. Bone and body composition of children andadolescents with repeated forearm fractures[J].J Bone Miner Res，2005，20(12)：2090-2096.
[37] Strauss AJ，Su JT，Dalton VM，et al. Bony morbidity in children treated for acutelymphoblastic leukemia [J]. J Clin Oncol，2001，19(12)，3066-3072.
[38] van der Sluis I，van den Heuvel-Eibrink M，Hahlen K，et al. Bone mineral density，bodycomposition，and height in long-term survivors of acute lymphoblastic leukemia inchildhood[J]. Med Pediatr Oncol，2000，35(4)：415-420.
[39] Bogunovic L，Doyle SM，Vogiatzi MG. Measurement of bone density in the pediatricpopulation [J]. Curr Opin Pediatr，2009，21(1)：77-82.
[40] Genant HK，Lang TF，Engelke K，et al. Advances in the noninvasive assessment of bonedensity，quality，and structure[J]. Calcif Tissue Int，1996，59(Suppl1)：S10-S15
[41] Chung H，Wehrli FW，Williams JL，et al.Relationships between NMR transverserelaxation，trabecular bone architecture，and strength[J].Proc Natl Acad Sci，1993，9(21)：10250-10254.
[42] Adams P，Davies G，Sweetnam P. Observer error and measurements of the metacarpal [J].Br J Radiol，1969，42(495)：192-197.
[43] Faulkner KG，Gluer CC，Majumdar S，et al. Noninvasive measurements of bone mass，structure，and strength：current methods and experimental techniques[J]. AJR Am JRoentgenol，1991，157(6)：1229-1237.
[44]弓健，徐浩.DXA骨密度测量质量控制中的精密度和准确度研究[J].中华核医学杂志，2005，25(6)：333-335.
[45] Xu H，Gong J，Chen JX，et al. Bilateral femoral bone mineral density measurements inChinese women and men [J]. J Clin Densitom，2007，10(2)：165-169.
[46] Khan AA，Bachrach L，Brown JP，et al. Standards and guidelines for performing centraldual-energy x-ray absorptiometry in premenopausal women，men，and children[J]. J ClinDensitom，2004，7(1)：51-64.
[47]向青，李春岩，苏楠，等. Z-值和T-值在骨密度测量中的意义[J].中国骨质疏松杂志，2003，9(3)：271-272.
[48] Rauch F，Plotkin H，DiMeglio L，et al. Fracture prediction and the definition ofosteoporosis in children and adolescents：the ISCD2007Pediatric Official Positions[J]. JClin Densitom，2008，11(1)：22-28.
[49] Gordon CM，Bachrach LK，Carpenter TO，et al. Dual energy X-ray absorptiometryinterpretation and reporting in children and adolescents：the2007ISCD Pediatric OfficialPositions [J]. J Clin Densitom，2008，11(1)：43-58.
[50] Keaveny TM，Hayes WC. A20-year perspective on the mechanical properties oftrabecular bone [J]. J Biomech Eng，1993，115(4B)：534-542.
[51] Amelio P，Rossi P，Isaia G，et al. Bone mineral density and singh index predict bonemechanical properties of human femur [J]. Connect Tissue Res，2008，49(2)：99-104.
[52] Martin RB，Burr DB. Non-invasive measurement of long bone cross-sectional moment ofinertia by photon absorptiometry [J]. J Biomech，1984，17(3)：195-201.
[53] Beck TJ，Ruff CB，Warden KE，et al. Predicting femoral neck strength from bonemineral data. A structural approach [J]. Invest Radiol，1990，25(1)：6-18.
[54] Yoshikawa T，Turner CH，Peacock M，et al. Geometric structure of the femoral neckmeasured using dual-energy x-ray absorptiometry [J]. J Bone Miner Res，1994，9(7)：1053-1064.
[55] Albanese CV，Diessel E，Genant HK. Clinical applications of body compositionmeasurements using DXA [J]. J Clin Densitom，2003，6(2)：75-85.
[56] Behnke AR，Feen BG，Welham WC. The specific gravity of healthy man：Bodyweight-volume as an index of obesity [J].1942，118：495-498.
[57]金婧，阮祥燕.体成分模型及测量方法研究进展[J].中国骨质疏松杂志，2007，13(9)：670-674.
[58]陆大江，陈佩杰，李效凯.身体成分测定方法介绍[J].中国运动医学杂志，2002，21(3)：332-336.
[59] Schreiner PJ，Pitkaniemi J，Pekkanen J，et al. Reliability of near infrared interactancebody fat assessment relative to standard anthropometric techniques [J]. Clin Epidemiol，1995，48(11)：1361-1367.
[60] Stolk RP， Wink O， Zelissen PM， et al. Validity and reproducibility of ultrasonographyfor the measurement of intra-abdominal adipose tissue [J]. Int J Obes Relat MetabDisord，2001，25(9)：1346-1351.
[61]黄海滨，任超世.生物电阻抗分析法(BIA)测量人体成分[J].国外医学生物医学工程分册，2000，23(3)：151-155
[62] Jensen MD，Kanaley JA，Reed JE，et al. Measurement of abdominal and visceral fat withcomputed tomography and dual-energy x-ray absorptiometry [J]. Am J Clin Nutr，1995，61(2)：274-278.
[63] Ross R，Goodpaster B，Kelley D，et al. Magnetic resonance imaging in human bodycomposition research. From quantitative to qualitative tissue measurement [J]. Ann N YAcad Sci，2000，904：12-17.
[64] Jennifer LD， James JD， David MA.The measurement of body segment inertialparametersusing dual energy X-ray absorptiometry [J]. J Biomech，2002，35(12)：1575-1580.
[65] Secor SM， Nagy TR. Non-invasive measure of body composition of snakes usingdual-energy X-ray absorptiometr [J]. Comp Biochem Physiol A Mol Integr Physiol，2003，136(2)：379-389.
[66] Suster D，Leury BJ，Ostrowska E，et al.Accuracy of dual energy X-ray absorptiometry(DXA)，weight and p2back fat to predict whole body and carcass composition in pigswithin and across experiments[J]. Livestock Production Science，2003，84(3)：231-242.
[67] Albanese CV， Diessel E， Genant HK.Clinical applications of body compositionmeasurements using DXA [J]. J Clin Densitom，2003，6(2)：75-85.
[68] Cobayashi F，Lopes L，Taddei J. Bone mineral density in overweight and obeseadolescents [J]. J Pediatr (Rio J)，2005，81(4)：337-342.
[69] Leonard MB，Shults J，Wilson BA，et al. Obesity during childhood and adolescenceaugments bone mass and bone dimensions[J].Am J Clin Nutr，2004，80(2)：514-523.
[70] Goulding A，Taylor RW，Jones IE，et al. Overweight and obese children have low bonemass and area for their weight[J].Int J Obes Relat Metab Disord，2000，24(5)：627-632.
[71] Goulding A，Taylor RW，Jones IE，et al. spinal overload：a concern for obese childrenand adolescents[J]? Osteoporos Int，2002，13(10)：835-840.
[72] Goulding A，Jones IE，Taylor RW，et al. Bone mineral density and body composition inboys with distal forearm fractures：a dual-energy X-ray absorptiometry study[J].J Pediatr，2001，139(4)：509-515.
[73] El Hage R，Moussa E，Jacob C.Femoral neck geometry in overweight and normal weightadolescent girls [J]. J Bone Miner Metab，2010，28(5)：595-600.
[74] El Hage Z，Theunynck D，Jacob C，et al.Hip bone strength indices in overweight andcontrol adolescent boys [J]. J Bone Miner Metab，2011，29(6)：691-698.
[75] Petit MA，Beck TJ，Shults J，et al. Proximal femur bone geometry is appropriatelyadapted to lean mass in overweight children and adolescents [J]. Bone，2005，36(3)：568-576.
[76]李金花. DXA股骨强度指数测量的临床应用研究.暨南大学硕士学位论文，2009.
[77]肖建德.实用骨质疏松学[M].北京:科学出版社，2004：103.
[78] E1Hage R，Jacob C，Moussa E，et al. Total body，lumbar spine and hip bone mineraldensity in overweight adolescent girls：decreased or increased [J]? J Bone Miner Metab，2009，27(5)：629-633.
[79] E1Hage R，Courteix D，Benhamou CL，et al. Relative importance of lean and fat masson bone mineral density in a group of adolescent girls and boys [J]. Eur J Appl Physiol，2009，105(5)：759-764.
[80] Schoenau E，Neu CM，Rauch F，et al. The development of bone strength at the proximalradius during childhood and adolescence [J]. J Clin Endocrinol Metab，2001，86(2)：613-618.
[81]邢晨芳，范国裕.青少年的骨量发育[J].中国妇幼保健，2008，23(11)：1585-1587.
[82] Thomas T，Burguera B. Is Leptin the link between fat and bone mass [J]? J Bone MinerRes，2002，17(9)：1563-1569.
[83] Rocher E，Chappard C，Jaffre′C，et al. Bone mineral density in prepubertal obese andcontrol children： relation to body weight，lean mass，and fat mass[J]. J Bone MinerMetab，2008，26(1)：73-78.
[84] Artz E，Haqq A，Freemark M. Hormonal and metabolic consequences of childhoodobesity [J]. Endocrinol Metab Clin North Am，2005，34(3)：643-658.
[85] Heber D，Ingles S，Ashley JM，et al. Clinical detection of sarcopenic obesity bybioelectrical impedance analysis [J]. Am J Clin Nutr，1996，64(3)：472S-477S.
[86] Clark EM，Ness AR，Tobias JH. Adipose Tissue Stimulates Bone Growth in PrepubertalChildren [J]. J Clin Endocrinol Metab，2006，91(7)：2534-2541.
[87] Yates LB，Karasik D，Beck TJ，et al.Hip structural geometry in old-old age：similaritiesand differences between men and women[J]. Bone，2007，41(4)：722-732.
[88] Faulkner KG，Cummings SR，Black D，et al. Simple measurement of femoral geometrypredicts hip fracture：the study of osteoporotic fractures[J]. J Bone Miner Res，1993，8(10)：1211-1217.
[89] Nakamura T，Turner CH，Yoshikawa T，et al. Do variations in hip geometry explaindifferences in hip fracture risk between Japanese and white Americans [J]? J Bone MinerRes，1994，9(7)：1071-1076.
[90] Alonso CG，Curiel MD，Carranza FH，et al. Femoral bone mineral density，neck-shaftangle and mean femoral neck width as predictors of hip fracture in men and women.Multicenter project for research in osteoporosis [J]. Osteoporos Int，2000，11(8)：714-720.
[91] Gnudi S，Ripamonti C，Lisi L，et al. Proximal femur geometry to detect and distinguishfemoral neck fractures from trochanteric fractures in postmenopausal women [J].Osteoporos Int，2002，13(1)：69-73.
[92] Bergot C，Bousson V，Meunier A，et al. Hip fracture risk and proximal femur geometryfrom DXA scans [J]. Osteoporos Int，2002，13(7)：542-550.
[93] Cummings SR，Cauley JA，Palermo L，et al. Racial differences in hip axis lengths mightexplain racial differences in rates of hip fracture. Study of osteoporotic fractures researchgroup [J]. Osteoporos Int，1994，4(4)：226-229.
[94] Gao G，Zhang ZL，Zhang H，et al. Hip axis length changes in10，554males and femalesand the association with femoral neck fracture[J]. J Clin Densitom，2008，11(3)：360-366
[95] Zhang H，Hu YQ，Zhang ZL，et al. Age trends for hip geometry in Chinese men andwomen and the association with femoral neck fracture [J]. Osteoporos Int，2011，22(9)：2513-2522.
[96] Beck T.Measuring the structural strength of bones with dual-energy X-ray absorptiometry:principles，technical limitations，and future possibilities [J]. Osteoporos，2003，14(Suppl5)：S81–S88.