Increased ApoB/ApoA1 ratio is associated with excess weight, body adiposity, and altered lipid profile in children

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www.jped.com.br

ORIGINAL

ARTICLE

Increased

ApoB/ApoA1

ratio

is

associated

with

excess

weight,

body

adiposity,

and

altered

lipid

proﬁle

in

children

夽

Ana

Paula

Pereira

Castro

∗

,

Helen

Hermana

Miranda

Hermsdorff,

Q1

Luana

Cupertino

Milagres,

Fernanda

Martins

Albuquerque,

Mariana

de

Santis

Filgueiras,

Naruna

Pereira

Rocha,

Juliana

Farias

de

Novaes

UniversidadeFederaldeViçosa(UFV),DepartamentodeNutriçãoeSaúde,Viçosa,MG,Brazil Received15July2017;accepted26December2017

KEYWORDS Children; Lipids; Anthropometry; Bodycomposition; Apolipoproteins Abstract

Objective: ToinvestigateApoB/ApoA1ratioanditsassociationwithcardiovascularriskfactors inchildren.

Methods: Cross-sectionalstudywith258childrenaged8and9yearsold,enrolledinallurban schoolsinthecityofVic¸osa-MG.Ananthropometricevaluationofthebodyandbiochemical compositionofthechildren wasperformed.Socioeconomicvariablesandsedentarylifestyle wereevaluatedthroughasemi-structuredquestionnaire.

Results: Manychildrenhadexcessweight(35.2%),abdominaladiposity(10.5%),andbodyfat (15.6%),aswellasincreasedApoB/ApoA1ratio(14.7%),totalcholesterol(51.8%),and triglyc-erides(19.8%).Childrenwithexcessweightandtotalandcentralfathadahigherprevalence ofhavingahigherApoB/ApoA1ratio,aswellasthosewithatherogeniclipidproﬁle(increased LDL-candtriglyceridesandlowHDL-c).Adirectassociationwasfoundbetweenthenumberof cardiovascularriskfactorsandtheApoB/ApoA1ratio(p=0.001),regardlessofageandincome. Conclusion: TheincreasedApoB/ApoA1ratiowasassociatedwithexcessweight,bodyadiposity (total andcentral), andaltered lipid proﬁle inchildren. Childrenwith ahigher number of cardiovascularriskfactorshadhigherApoB/ApoA1ratio,inbothgenders.

夽 _Please_cite_this_article_as:_Castro_AP,_Hermsdorff_HH,_Milagres_LC,_Albuquerque_FM,_Filgueiras_MS,_Rocha_NP,_et_al._Increased_ApoB/ApoA1

ratioisassociatedwithexcessweight,bodyadiposity,andalteredlipidproﬁleinchildren.JPediatr.2018.https://doi.org/10.1016/j.jped. 2017.12.008

∗_{Corresponding}_author.

E-mail:anaenut@gmail.com(A.P.Castro).

https://doi.org/10.1016/j.jped.2017.12.008

0021-7557/©2018SociedadeBrasileiradePediatria.PublishedbyElsevierEditoraLtda.ThisisanopenaccessarticleundertheCCBY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/). 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

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PALAVRAS-CHAVE

Crianc¸as; Lipídios; Antropometria; Composic¸ãocorporal; Apolipoproteínas

ArazãoApoB/ApoA1aumentadaestáassociadaaoexcessodepeso,deadiposidade corporaleaoperﬁllipídicoalteradoemcrianc¸as

Resumo

Objetivo: InvestigararazãoApoB/ApoA1esuarelac¸ãocomfatoresderiscocardiovascularem crianc¸as.

Métodos: Trata-sedeumestudotransversalcom258criançasde8e9anos,matriculadasem todasescolasurbanasdeViçosa-MG.Foirealizadaavaliaçãoantropométrica,dacomposição cor-poralebioquímicadascrianças.Asvariáveissocioeconômicaseosedentarismoforamavaliados porquestionáriosemiestruturado.

Resultados: Muitascriançasapresentaramexcessodepeso(35,2%),deadiposidadeabdominal (10,5%)edegorduracorporal(15,6%),bemcomoarazãoApoB/ApoA1(14,7%),colesterol-total (51,8%)etriglicerídeos(19,8%)aumentados.Criançascomexcessodepesoedegorduratotale centralapresentarammaioresprevalênciasdetermaiorrazãoApoB/ApoA1,bemcomoascom perfillipídicoaterogênico(LDL-cetriglicerídeosaumentadosebaixoHDL-c).Foiencontrada associação diretaentreo númerode fatoresde riscocardiovasculare arazãoApoB/ApoA1 (p=0,001),independentedaidadeerenda.

Conclusão: ArazãoApoB/ApoA1aumentadaesteveassociadaaoexcessodepeso,de adiposi-dadecorporal(totalecentral)eaoperfillipídicoalteradonascrianças.Ascriançascommaior númerodefatoresderiscocardiovascularapresentarammaiorrazãoApoB/ApoA1,emambos ossexos.

Introduction

Exposuretotheatherogeniclipidproﬁlemayinducechanges in thearteries and contribute toatherosclerosis develop-ment,which may start inchildhood.1 _Studies _have _shown

thatelevatedLDLcholesterollevelsinchildren predictan increaseintheintima-medialayerthicknessofthearteries inadults.2_Considering_this_fact,_it_is_important_to_measure

serumlipidlevelsinchildhoodasastrategyaimedtoprevent cardiovasculardiseasesandatherosclerosis.

The ratio between pro-atherogenic (containing ApoB) and anti-atherogenic particles (containing ApoA1) may be associated with cardiovascular diseases.3 _ApoA1 _is

the main protein of the HDL-c particle, responsible for stimulating reverse cholesterol transport, removing excess from the tissues and redirecting it to the liver. Moreover, it can inhibit LDL-c oxidation, helps in the removal of toxic products, and it has anti-inﬂammatory properties.4 _In _turn, _ApoB _is _part _of _the _atherogenic

lipid fractions, including LDL-c, an intermediate-density lipoprotein(IDL),verylow-densitylipoprotein (VLDL),and lipoprotein(a).5

Thus, the ApoB/ApoA1 ratio has been investigated as a possible cardiometabolic predictor for atheroscle-rosis in adults.6 _In _children, _studies _have _shown _that

the ApoB/ApoA1 ratio is associated with metabolic syn-dromecomponents,suchasincreasedwaistcircumference and blood pressure, low HDL-c, and high triglycerides.7,8

Additionally, lifestyle changes in obese children, such as sedentary lifestyle, seem to inﬂuence the higher ApoB/ApoA1ratio.9

However,thereisagapintheknowledgeonthe associa-tionbetweentheApoB/ApoA1ratioandcardiovascularrisk

factorsinchildren,withthissubjectbeingscarcelystudied inBrazil10 _and_in_other_countries_in_this_age_group.7,8

AstheincreasedApoB/ApoA1ratiomaycontributetothe occurrenceofatheroscleroticevents inadultlife,theaim ofthisstudy wastoinvestigatetheApoB/ApoA1ratioand its association withcardiovascular risk factors in children enrolledinurbanschoolsinthemunicipalityofVic¸osa,state ofMinasGerais,Brazil.

Methods

Studypopulationandsamplingprocess

Thisisacross-sectionalstudyconductedbetweenMayand December of 2015, with a sample of 258 children aged 8 and 9 years, enrolled in all public (n=17) and private (n=7) schools in the urban area of the municipality of Vic¸osa,Minas Gerais, Brazil.This study ispart of alarger projectentitled‘‘VitaminDinchildhood:intake,serum lev-els,andassociationwithcardiovascularriskfactors,’’from theSchoolchildren’sHealthAssessmentSurvey(Pesquisade Avaliac¸ãodaSaúdedoEscolar---PASE).

The sample wascalculated using the OpenEpi statisti-calprogram(OpenSourceEpidemiologicStatisticsforPublic Health,version3.01),consideringtheprevalenceof50%for multiple outcomes, tolerable error of 5%, plus 10% losses and10%confoundingfactors,totalingasamplesizeof366 children.

FortheevaluationoftheApoB/ApoA1ratio,asubsample of258childrenwasused,sincethebloodvolumecollected wasnotenoughfortheApoBandApoA1measurementinall thechildrenfromtheoriginalproject.Itisworthmentioning 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112

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thattheﬁnalsampledidnotdifferfromtheoriginalsample inrelationtogender,age,andcardiovascularriskfactors.

Astratiﬁedrandomsamplingprocesswasperformedon theschoolchildren,inwhich thenumberofchildrentobe sampled in each school was related to the weighting by school,accordingtoitssize.Subsequently,thechildrenwere selectedbydrawinglotsfromarandomnumbertable,until thenumberofstudentsneededperschoolwascompleted.

Aftercontactingtheparents,thechildrenwereinvited toparticipateinthestudy.Thosewhousedmedicationsthat interferedwithglucoseand/orlipidmetabolismandthose withspecialneedswerenotincludedinthestudy.

Datacollection

Weightandheightweremeasuredusinganelectronic digi-talscale(Tanita®,modelBC553,IL,USA),withacapacity of150kilogramsandasensitivityof100grams.Weightwas measured withthe individuals in theorthostatic position, barefoot,andwearinglightclothing.Heightwasmeasured using a portable vertical stadiometer (Alturexata®, MG, Brazil),measuring2meters,graduatedincentimetersand subdividedintomillimeters.Bodymassindex(BMI)was cal-culatedbasedontheobtainedvalues.Nutritionalstatuswas evaluatedbasedonBMI/age,andchildrenwithz-score≥−2

and<1wereconsidered ashavingnormalweight,whereas those with z-score ≥1 were considered as having excess weight(overweightorobesity).11

Waistcircumference(WC)wasmeasuredatthemidpoint between the iliac crest and the last ribusing a ﬂexible, inelasticmeasuringtape,graduatedincentimetersand sub-dividedintomillimeters.Excessiveabdominaladipositywas considered in thepresence of valuesabove the90th per-centileaccordingtoageandgender.12 _The _{waist-to-height}

ratio(WHtR)wascalculatedbydividingthewaist measure-ment(cm)byheight(cm),andvalues≥0.5wereusedto classifyexcessabdominaladiposity.13

The total and central body fat (android fat [AF] and gynoidfat[GF])wasevaluatedinthesupineposition,using thedual-energyX-rayabsorptiometry(DXA)methodinthe Diagnostic Imaging Sector of the Health Division of Uni-versidadeFederal deVic¸osa.The AFcomprises theregion between the ribs and the pelvis,with the uppermarking beingmadeat20%ofthedistancefromtheiliaccrestand neck,andthelowermarkingbeingmadeabovethepelvis. The gynoidregionmeasurementsincluded thehip,thighs, andoverlaps oftheleg andtrunkregions, withthe upper markingbeingmadebelowthe iliaccrestat adistanceof 1.5timestheandroidheight.14_Excess_body_fat_was_classiﬁed

withvalues≥85thpercentileforageandgender,according toMcCarthyetal.15

Theneckcircumference(NC)wasassessedinthe Frank-furthorizontalplane,withthechildstandingerect,usingan inextensiblemeasuringtape(TBW®,SP,Brazil),justbelow thelaryngealprominenceintheneck,perpendiculartothe largest axisof theneck. Minimalpressure wasexertedto allowfullcontactofthetapewiththeskin.Theincreased values wereclassiﬁed according to the cutoffpoints pro-posedbyNaﬁeuetal.16

Waistcircumference(WC),waist-to-heightratio(WHtR), neck circumference, and android/gynoid fat ratio were

consideredindicatorsofcentraladiposity,whereasBMIwas theindicatoroftotaladiposity.

Bloodpressure(BP)wasmeasuredthreetimes,withthe childinthesittingpositionwithfive-minuteintervals, con-sideringthemeanvalueforBPclassificationaccordingtothe 7thBrazilianGuidelineofArterialHypertension.Highblood pressure was classified as systolic (SBP) and/or diastolic (DBP)bloodpressureabovethe95thpercentile,accordingto age,gender,heightpercentile,onatleast threedifferent occasions.17 _BP _was_measured _using _the_automatic _device

(Omron®,HEM907,IL,USA).

Venous blood samples were collected between eight and ten a.m., after overnight fasting, and centrifuged at 1000×g for 10min at 4◦C. Levels of total choles-terol(TC),HDL-c,LDL-c,triglycerides(TG),andC-reactive protein(CRP) weremeasured usingthe colorimetric enzy-maticmethodusingacommercialkit(Bioclin®,MG,Brazil) in an automated analyzer (BS-200 Mindray®, China) at theLaboratory of Clinical Analyses (LAC)of the Nutrition andHealthDepartmentofUniversidadeFederal deViçosa (UFV).Non-HDL-cholesterolwasestimatedbytheformula: Non-HDL-c=TC-HDL-c. The lipid profile classification was performedaccordingtotheBrazilianSocietyofCardiology.18

Theserumlevelsofleptin,ApoA1,ApoBandhomocysteine wereanalyzedthroughcommercialELISAkits,nephelometry (BeckmanCoulter,CA,USA),andchemiluminescence (stan-dardized protocols from Diagnóstico Brasil), respectively. Intra-assay variations were 4% for both ApoA1 and ApoB. Becausetherewereno cutoffpointsfor the classiﬁcation oftheultra-sensitive C-reactive protein,leptin, homocys-teine, ApoA1 and ApoB in the studied age group, values ≥85thpercentilewereconsideredatrisk.

A semi-structured questionnaire was applied person-ally by trained interviewers to parents or guardians to assesssociodemographicvariables,suchasgenderand fam-ily incomeper capita, and total timeof physical activity (TPA). The children were classiﬁed as active when they performed 300minutes or more of moderate or vigorous physicalactivityweeklyandwereconsideredinactivewhen theyperformed lessthan 300minutes,asclassiﬁedbythe NationalSchoolHealthSurvey.19 _It_is_important_to_mention

thatnoneofthegirlshadexperiencedmenarcheatthetime ofthisstudy.

Statisticalanalysis

The normality of the data was veriﬁed by the Kolmogorov---Smirnov test. Pearson’s chi-squared test andFisher’s exact test were used tocompare the preva-lenceof cardiovascular risk factors between genders and ApoB/ApoA1values.

Poisson regression was performed with crude and adjusted robust variance to analyze the associations between ApoB/ApoA1 ratio and age, time of physical activity,anthropometricvariables, body composition,and clinical and biochemical variables. Variables with a sig-niﬁcance level ≤0.20 were included in the regression model. According with the linear regression analysis, the ApoB/ApoA1ratiowasalsoevaluatedaccordingtothe num-berof cardiovascularrisk factors(TPA, WHtR, CT, HDL-c, LDL-c, TG, non-HDL cholesterol, AF/GF, excess weight). 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230

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Table1 Distributionofthechildren’sage,physicalactivitytime,anthropometric,bodycomposition,andbiochemicalvariables, accordingtogender;Vic¸osa,MG,Brazil,2015.

Variables Boys,n(%) Girls,n(%) p

Age 8years 60(53.6) 65(44.5) 0.149 9years 52(46.4) 81(55.5) PAT Active(>300min/week) 78(69.6) 117(80.1) 0.052 Inactive(≤300min/week) 34(30.4) 29(19.9) Waist/heightratio ≤0.5 18(16.1) 30(20.5) 0.360 >0.5 94(83.9) 116(79.5) Excessweight No(z-score≥−2and<1) 74(66.1) 93(63.7) 0.693 Yes(z-score_≥1) 38(33.9) 53(36.3) Neckcircumference(cm) Normal 97(86.6) 121(82.9) 0.412 Increased 15(13.4) 25(17.1) Waistcircumference(cm) <90thpercentile 100(89.3) 131(89.7) 0.909 ≥90thpercentile 12(10.7) 15(10.3) Bodyfat(%) <85thpercentile 96(85.7) 121(82.9) 0.537 ≥85thpercentile 16(14.3) 25(17.1) GF/AF(%) <85thpercentile 95(84.8) 123(84.2) 0.899 ≥85thpercentile 17(15.2) 23(15.8) SBP(mmHg) Normal 105(93.8) 136(93.8) 0.989 Increased 7(6.2) 9(6.2) DBP(mmHg)↑ Normal 108(96.4) 143(98.6) 0.408 Q2 Increased 4(3.6) 2(1.4) ApoB(mg/dL) <85thpercentile 99(88.4) 122(83.6) 0.272 ≥85thpercentile 13(11.6) 24(16.4) ApoA1(mg/dL) <85thpercentile 24(21.4) 14(9.6) 0.008 ≥85thpercentile 88(78.6) 132(90.4) ApoB/ApoA1 <85thpercentile 99(88.4) 121(82.9) 0.215 ≥85thpercentile 13(11.6) 25(17.1) Totalcholesterol(mg/dL) <150 54(48.2) 70(48.3) 0.992 ≥150 58(51.8) 75(51.7) Triglycerides(mg/dL) <100 98(87.5) 108(74.5) 0.009 ≥100 14(12.5) 37(25.5) LDL-c(mg/dL) <100 80(72.1) 104(71.2) 0.883

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Table1(Continued)

Variables Boys,n(%) Girls,n(%) p

≥100 31(27.9) 42(28.8) HDL-c(mg/dL) <45 87(77.7) 94(64.8) 0.025 ≥45 25(22.3) 51(32.5) Non-HDL-c(mg/dL)↑ <130 110(98.2) 143(97.9) 1.00 ≥130 2(1.8) 3(2.1) UltrasensitiveCRP(mg/L) <85thpercentile 100(89.3) 135(92.5) 0.374 ≥85thpercentile 12(10.7) 11(7.5) Leptin(ng/mL) <85thpercentile 99(89.2) 107(76.4) 0.009 ≥85thpercentile 12(10.8) 33(23.6) Homocysteine(ng/mL) <85thpercentile 83(74.1) 113(77.4) 0.540 ≥85thpercentile 29(25.9) 33(22.6)

TPA,totaltimeofphysicalactivity;BMI,bodymassindex;GF,gynoidbodyfat;AF,androidbodyfat;SBP,systolicbloodpressure; DBP,diastolicbloodpressure;ApoB,apolipoproteinB;ApoA1,apolipoproteinA1;LDL-c,low-densitylipoprotein;HDL-c,high-density lipoprotein;CRP,C-reactiveprotein.Pearson’schi-squaredtestandFisher’sexacttest.

Statistical analyses were performed using the software SPSS® (SPSS for Windows, Version 16.0., Chicago, USA) and Stata (Stata Statistical Software:Release 10, College Station,TX,USA).Valuesofp<0.05wereconsidered statis-ticallysigniﬁcant.

Ethicalaspects

This study was carried out in accordance with the guidelines deﬁned in the Declaration of Helsinki and all procedures involving human subjects were approved by the Human Research Ethics Committee of Universi-dade Federal deVic¸osa(UFV;Opinion No.663.171/2014). Informed consent was obtained from all parents or legal guardians, after they were informed about the study objectives.

Results

A total of 258 children were evaluated, 56% females. Many children had excess weight (35.2%), abdominal adi-posity(10.5%), andbodyfat (15.6%),aswell asincreased ApoB/ApoA1ratio(14.7%),serumlevelsoftotalcholesterol (51.8%),andtriglycerides(19.8%).Additionally,8.9%,17.9%, and24%ofthechildrenhadincreasedserumlevelsof ultra-sensitive CRP,leptin,andhomocysteine,respectively. The prevalence ofreducedserumApoA1andHDL-c levelswas higherinboysthaningirls.Inturn,girlshadahigher preva-lenceofincreasedserumlevelsoftriglyceridesandleptin (Table1).

ChildrenwithahigherApoB/ApoA1ratioweremore inac-tive,hadincreasedWHtR,excessweight,andalteredlipid proﬁle(Table2).

Inregressionmodels,childrenwithindicatorsoftotaland centraladiposity(WHtR,waistcircumference,bodyfat,and AF/GF)hadahigherprevalenceofhigherApoB/ApoA1ratio (>85thpercentile),regardlessofgender,age,andincome. Interestingly,childrenwithanatherogeniclipidproﬁle(total cholesterol,LDL-c,non-HDL-c, andincreasedtriglycerides and low HDL-c) also had a higher prevalence of a higher ApoB/ApoA1ratio,regardlessofgender,age,income,and bodyfat(Table3).

Childrenwithahighernumberofcardiovascularrisk fac-torshadahigherApoB/ApoA1ratio,regardlessofageand income,inbothgirlsandboys(Fig.1).

Discussion

Inthepresentstudy,ahigherApoB/ApoA1ratiowas asso-ciated with excess body weight and adiposity (total and central),aswellasanalteredlipidproﬁleinchildren.There wasadirectassociationbetweenthenumberof cardiovas-cularriskfactorsand theApoB/ApoA1ratio,regardlessof ageandincome.

InchildrenandadolescentsfromCanada,anassociation wasalsofoundbetweentheincreasedApoB/ApoA1ratioand excessweight.7_In_a_study_carried_out_in_the_United_States,

childrenandadolescentswithnormalweightandabdominal obesity(WHtR≥0.5cm)hadahighernumberof cardiovas-cularriskfactors,suchashypertension,increasedlevelsof triglycerides,andLDL-c,aswellasinsulinresistancewhen comparedtothosewithoutabdominalobesity.20_In_Brazilian

childrenandadolescents,theApoB/ApoA1ratiowas associ-atedwithmorethanonecardiovascularriskfactor(BMI,WC, WHtR,HDL-c,andtriglycerides),corroboratingthepresent ﬁndings.10 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290

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Table2 Distributionof children’s physical activitytime, anthropometric, body composition, and biochemistry variables, accordingtoApoB/ApoA1ratio;Vic¸osa,MG,Brazil,2015.

Variables ApoB/ApoA1,<85thpercentile,n(%) ApoB/ApoA1,_≥85thpercentile,n(%) p TPA Active(>300min/week) 172(78.2) 23(60.5) 0.019 Inactive(≤300min/week) 48(21.8) 15(39.5) Waist/heightratio ≤0.5 185(84.1) 25(65.8) 0.007 >0.5 35(15.9) 13(34.2) Excessweight No(z-score_≥−2and<1) 150(68.2) 17(44.7) 0.005 Yes(z-score≥1) 70(31.8) 21(55.3) Neckcircumference(cm) Normal 188(85.5) 30(78.9) 0.306 Increased 32(14.5) 8(21.1) Waistcircumference(cm)↑ ≤90thpercentile 22(10.0) 5(13.2) 0.567 >90thpercentile 198(90.0) 33(86.8) Bodyfat(%) <85thpercentile 188(85.5) 29(76.3) 0.155 ≥85thpercentile 32(14.5) 9(23.7) GF/AF(%) <85thpercentile 190(86.4) 28(73.7) 0.046 ≥85thpercentile 30(13.6) 10(26.3) Totalcholesterol(mg/dL) <150 116(53.0) 8(21.1) <0.001 ≥150 103(47.0) 30(78.9) Triglycerides(mg/dL) <100 186(84.9) 20(52.6) <0.001 ≥100 33(15.1) 18(47.4) LDL-c(mg/dL) <100 171(78.1) 13(34.2) <0.001 ≥100 48(21.9) 25(65.8) HDL-c(mg/dL) <45 165(75.3) 16(42.1) <0.001 ≥45 54(24.7) 22(57.9) Non-HDL-c(mg/dL) <130 196(89.1) 21(55.3) <0.001 ≥130 24(10.9) 17(44.7) Leptin(ng/mL) <85thpercentile 178(83.2) 28(75.7) 0.272 ≥85thpercentile 36(16.8) 9(24.3) PCR(mg/L) <85thpercentile 187(85) 30(78.9) 0.346 ≥85thpercentile 33(15) 8(21.1) Homocysteine(ng/mL) <85thpercentile 168(76.4) 28(73.7) 0.686 ≥85thpercentile 52(23.6) 10(26.3)

TPA,totaltimeofphysicalactivity;BMI,bodymassindex; GF,gynoidbodyfat;AF,androidbodyfat;SBP, systolicbloodpressure; DBP,diastolicbloodpressure;ApoB,apolipoproteinB;ApoA1,apolipoproteinA1;LDL-c,low-densitylipoprotein;HDL-c,high-density lipoprotein;CRP,C-reactiveprotein.Pearson’schi-squaredtestandFisher’sexacttest.

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Table3 Associationbetween the increasedApoB/ApoA1 ratio (dependent variable) and anthropometric, body composition,andbiochemicalvariablesinchildren;Vic¸osa, MG,Brazil,2015.

Variables ApoB/ApoA1(≥85thpercentile)

PR 95%CI p-value TPAa Active(_≥ 300 min-utes/week) 1 ---Inactive (<300 min-utes/week) 1.31 0.63 ---2.75 0 .432 Nutritionalstatusb Normal weight 1 ---Excess weight 2.14 1.20 ---3.80 0 .001 Waist/heightratiob <0.5 1 ---≥0.5 2.21 1.24 ---3.94 0 .004 Waistcircumferenceb <90th percentile 1 ---≥90th percentile 1.82 1.02 ---3.25 0 .003 Bodyfatb Boy<20%, girl<25% 1 ---Boy≥ 20%,girl ≥25% 1.92 1.02 ---3.61 0 .009 AF/GFb <85th percentile 1 ---≥85th percentile 1.80 0.93 ---3.47 0 .003 Totalcholesterolc <150mg/dL 1 ---≥150mg/dL 3.39 1.61 ---7.12 <0 .001 Table3 (Continued)

Variables ApoB/ApoA1(≥85thpercentile)

PR 95%CI p-value HDL-cc >45mg/dL 1 ---<45mg/dL 2.98 1.62 ---5.49 <0 .001 LDL-cc ₁ ---<100mg/dL ≥100mg/dL 4.66 2.55 ---8.54 <0 .001 Non-HDL-cc <130mg/dL 1 ---≥130mg/dL 3.49 1.39 ---8.77 <0 .001 Triglycerides <100mg/dL 1 ---≥100mg/dL 3.59 2.06 ---6.25 <0 .001

TPA,timeofphysicalactivity;AF,androidfat;GF,gynoidfat; HDL-c,high-density lipoprotein;BMI,bodymassindex;LDL-c, lowdensitylipoprotein.

AdjustedPoissonregression:

a _Adjustment_by_gender,_age,_and_income.

b _Adjustment_by_gender,_age,_income,_and_physical_activity. c _Adjustment_by_gender,_age,_income,_and_body_fat.

Excesscentral adiposity has been considered the main component of the metabolic syndrome and is strongly associated with dyslipidemia and an increase in the number of cardiovascular risk factors, both in adults21

and children.22 _Excess _central _adiposity _may _lead _to _an

increasedApoB/ApoA1ratiothroughdifferentmechanisms: (1) decreased hepatic LDL receptor and/or decreased lipoprotein lipase (LPL) activity, both important for the removal of remaining chylomicrons from the circulation containing ApoB molecules23,24_; ₍₂₎ _increased _adipokine

secretionbyadiposetissueinobeseindividuals;(3) reduc-tion in serum HDL-c levels, the main characteristic of dyslipidemiaassociatedwithcentralobesity.25_In_obese

indi-viduals,thelowHDL-clevelisaconsequenceoftheincrease in HDL-c catabolism, thus favoring a decrease in ApoA1 levels.26 _Moreover, _body _fat _accumulation _is _one _of _the

mainfactorsthatcanmodifysmall-densityLDLexpression, becauseinboth adultsandchildren, abdominalobesity is

291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308

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0.90 0.80 0.70 0.60 0.50 0.40 0.30 0.90 0.80 0.70 0.60 ApoB/ApoA1 r atio (95% CI) ApoB/ApoA1 r atio (95% CI) 0.50 0.40 0.46 n=22 0.58 n=36 n=25 n=62 0.76 0.66 n=19 0.56 0.45 n=30 n=27 n=35 Boys Girls 0.73 0.62 β: 0.10; 95% CI: 0.08-0.12 β: 0.09; 95% CI: 0.06-0.13 p<0.001 p<0.001 0 1 2 ≥ 3 0 1 2 _{≥ 3}

Cardiovascular risk factors Cardiovascular risk factors

Figure1 Associationbetween theApoB/ApoA1ratio andthenumber ofcardiovascularrisk factorsinchildren, accordingto gender.Mean(95%CI),Linearregressionadjustedforageandincome;Vic¸osa,MG,Brazil,2015.

associatedwiththelowerdensity andthesmallerparticle sizeofLDL-c.27

It is worth mentioning that, in this study, children withthreeor morecardiovascular risk factors hadhigher ApoB/ApoA1ratiovaluesinbothgenders.Thisdirect asso-ciation suggests thepossible inﬂuence of pro-atherogenic particles (containingApoB) and anti-atherogenic particles (containingApoA1)oncardiovasculardiseases, asthereis anincreaseinthenumberofriskfactors.Todate,no simi-larstudieshavebeenfound,andthus,theresultsindicate the precocity of this association occurring as early as in childhood.

Thepresentstudyshowednoassociationbetweenserum levelsof leptin, CRP,and homocysteinewithApoB/ApoA1 ratio.Onepossiblehypothesisisthatthesemarkers partici-patein the cardiometabolicrisk throughapathway other than the ApoB/ApoA1 ratio, with these being recognized asimportantindicators ofsubclinical inﬂammation, while apolipoproteinsareinvolvedinlipidmetabolism.28_However,

todate, noother studieshave been foundthat evaluated the association between a higher ApoB/ApoA1 ratio and thesecardiometabolicmarkers,aswellasthemechanisms involved.

One limitation of this study is the fact that it has a cross-sectionaldesign,whichdoesnotallowforestablishing cause-and-effect associations. It is important to empha-sizethatfewBrazilianstudieshaveevaluatednon-classical cardiovascular markers, such as the ApoB/ApoA1 ratio, in healthyprepubertal children. As thesealterations may contribute to the onset of atherosclerotic disease, early identiﬁcation is crucial for the planning and implementa-tionofpublichealthpolicies,withactionsdirectedatfood and nutritional educationand the stimulation of physical activity.These actions may contribute to reducing future mortalityfrom cardiovascular diseases and other obesity-relateddiseases.

Insummary, a higherApoB/ApoA1ratiowasassociated withexcessweight,bodyadiposity(totalandcentral),and alteredlipidproﬁleinchildren.Childrenwithahigher num-ber of cardiovascular risk factors had higherApoB/ApoA1 ratio,regardlessofageandincome.

Funding

Conselho Nacional de Desenvolvimento Cientíﬁco e Tec-nológico(CNPq--- processn.478910/2013-4)andBioclin.

Conﬂicts

of

interest

Theauthorsdeclarenoconﬂictsofinterest.

Acknowledgements

The authors would like to thank the children and their parents for their participation in the study, to Conselho NacionaldeDesenvolvimentoCientíficoeTecnológico(CNPq ---processNo.478910/2013-4) forthefinancialsupport,to CoordenaçãodeAperfeiçoamentodePessoaldeNível Supe-rior(CAPES)forthegrantandtoBioClinforthedonationof kitsforbiochemicalanalyses.

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