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Published in final edited form as: Respir Physiol Neurobiol. 2024 Feb 9;323:104230. doi: 10.1016/j.resp.2024.104230

Pediatric patients diagnosed as overweight and obese have an elevated risk of dyspnea

Lydia S Robson 1, Abidan Abulimiti 2, Jorge Z Granados 2, Ayesha N Zia 3, Bryce N Balmain 2, James A Pawelczyk 4, Tony G Babb 2
PMCID: PMC10947832  NIHMSID: NIHMS1968408  PMID: 38340972

Abstract

We investigated whether pediatric patients with overweight and obesity are more likely to have dyspnea compared with those who are non-overweight. We collected de-identified data from TriNetX, a global federated multicenter research database, using both the UT Southwestern Medical Center and multinational Research Networks. Our analysis focused on patients aged 8-12 years. We identified overweight and obesity using ICD-10-CM codes E66 and dyspnea using code R06.0. Patients with overweight and obesity had a significantly higher risk of dyspnea compared with those who were non-overweight. This association was observed in both the UT Southwestern Network (risk ratio: 1.81, p<0.001) and the Research Network (risk ratio: 2.70, p<0.001). Furthermore, within the UT Southwestern Network, the risk was found to be higher in females compared with males (risk ratio: 2.17 vs. 1.73). These results have significant clinical implications, suggesting that clinicians should consider overweight and obesity as independent risk factors for dyspnea in pediatric patients after excluding other possible contributing factors.

Keywords: Obesity, Overweight, Dyspnea, Children

Introduction

Obesity and its associated comorbidities continue to be a growing issue in the United States and worldwide. The most recent data published by the National Center for Health Statistics reports the prevalence of overweight and obesity in children in the United States to be over 35%(Fryar et al., 2020). Pediatric obesity can cause significant physiological changes and is associated with numerous comorbidities affecting most organ systems, including the pulmonary system (Kumar and Kelly, 2017). In children, the respiratory effects of obesity have been most strongly associated with asthma and obstructive sleep apnea(Papoutsakis et al., 2013; Verhulst et al., 2007). In adults, obesity has also been associated with dyspnea(Goh et al., 2023; Sin et al., 2002) However, little is known about the associations between obesity and dyspnea in children.

Dyspnea on exertion is a common symptom of numerous chronic diseases affecting the respiratory and cardiovascular systems in pediatric patients, such as asthma, vocal cord dysfunction, heart failure, and cardiovascular deconditioning. Clinicians may encounter children who continue to complain of dyspnea on exertion even after these common causes have been excluded, thus leaving patients and families frustrated by the lack of answers and treatment options. Some patients may be misdiagnosed and prescribed treatment despite a lack of evidence of disease, thus leading to lack of clinical improvement and unnecessary medication use (Aaron et al., 2008). Obesity has been associated with dyspnea in otherwise healthy adults (Babb et al., 2008; Bernhardt and Babb, 2014; Bernhardt et al., 2014; Bernhardt et al., 2013). However, the association between obesity and dyspnea in otherwise healthy children is unknown. Because the association between obesity and dyspnea has been established among otherwise healthy adults (Goh et al., 2023), we hypothesize that this relationship may also exist in children. Given the high prevalence of pediatric obesity and that many children with obesity remain or become more obese in adulthood, it is critical to understand its relationship with dyspnea to provide a more accurate diagnosis, develop new treatment interventions, and reduce unnecessary medication use.

Therefore, the aim of this study was to investigate whether pediatric patients with overweight and obesity are more likely to have a diagnosis of dyspnea compared with pediatric patients who are non-overweight. We hypothesized that pediatric patients with overweight and obesity are more likely to have a diagnosis of dyspnea compared with pediatric patients who are non-overweight. Secondarily, this study also aimed to determine the prevalence of overweight and obesity among all patients aged 8 to 12 years.

Methods

Study population

This study was a retrospective cohort study using data obtained from de-identified electronic medical records (EMR). Data was extracted from TriNetX, which is a global online database that provides access to diagnoses, procedures, medications, laboratory values, and genomic information of various patient populations (Goh et al., 2023). TriNetX, LLC is compliant with the Health Insurance Portability and Accountability Act (HIPAA) and any additional data privacy regulations applicable to the contributing healthcare organization (HCO). TriNetX is certified to the ISO 27001:2013 standard and maintains an information security management system to ensure the protection of the healthcare data it has access to and to meet the requirements of the HIPAA Security Rule. Data displayed on the TriNetX Platform in aggregate form only contains de-identified data as per the de-identification standard defined in Section §164.514(a) of the HIPAA Privacy Rule. The data de-identification process is attested to through a formal determination by a qualified expert as defined in Section §164.514(b)(1) of the HIPAA Privacy Rule. Because this study used only de-identified patient records and did not involve the collection, use, or transmittal of individually identifiable data, this study was exempted from Institutional Review Board approval.

The data used in this retrospective cohort study were collected on November 16, 2022 from the TriNetX University of Texas Southwestern Medical Center (UTSW) and Research Networks. The UTSW Network provided access to EMR from 4,651,992 patients from 1 HCO. The Research Network provided access to EMR from 106,509,570 patients from 71 different HCOs in 3 different countries. Children 8 to 12 years of age were included in this study. This age range was selected because these children have similar lung and chest wall development, as well as similar predicted pulmonary function. Individuals were categorized as overweight and obese if they were diagnosed with overweight and obesity (ICD-10-CM E66) or had a reported body mass index (BMI) greater than or equal to the 85th percentile reported at any time. These patients were compared to other children their age who did not have a diagnosis of overweight and obesity (ICD-10-CM E66) or a reported BMI greater than or equal to the 85th percentile reported at any time. Patients diagnosed with significant pulmonary and cardiac comorbidities likely to cause dyspnea such as asthma, chronic lung disease, pulmonary embolism, heart failure, etc. were excluded (see Table 1 for comprehensive list). Additional data were collected to quantify the total number of patients ages 8 to 12 with overweight and obesity or BMI greater than or equal to the 85th percentile reported at any time without any exclusion criteria.

Table 1:

Inclusion and exclusion criteria used for patient selection from the TriNetX UTSW and Research Networks.

       Males and females 8-12 years of age
Overweight and obese cohort: Diagnosed with overweight and obesity (ICD-10-CM E66) or reported BMI ≥ 85th percentile
Non-overweight cohort: Never diagnosed with overweight and obesity (ICD-10-CM E66) or reported BMI ≥ 85th percentile
Patients diagnosed with and without dyspnea (ICD-10-CM R06.0)
Asthma (ICD-10-CM J45)
Bronchopulmonary dysplasia originating in the perinatal period (ICD-10-CM P27.1)
Complications and ill-defined descriptions of heart disease (ICD-10-CM I51)
Cystic fibrosis (ICD-10-CM E84)
Heart failure (I50)
Muscular dystrophy (ICD-10-CM G71.0)
Other chronic obstructive pulmonary disease (ICD-10-CM J44)
Other disorders of lung (ICD-10-CM J98.4)
Other interstitial pulmonary diseases (ICD-10-CM J84)
Other specified congenital malformations of respiratory system (ICD-10-CM Q34.8)
Pulmonary embolism (ICD-10-CM I26)
Sleep apnea (ICD-10-CM G47.3)
Vaping-related disorder (ICD-10-CM U07.0)
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BMI: body mass index; UTSW: University of Texas Southwestern Medical Center.

Statistical analysis

The primary outcome of interest was the diagnosis of dyspnea (ICD-10-CM R06.0) in patients categorized as overweight and obese compared to those who were not categorized as overweight and obese. Further analysis was divided by sex. Risk ratios (RR) with 95% confidence intervals (CI) and chi-square tests (two-sided) were performed using 2x2 contingency tables. The significance level was set as p-value ≤ 0.05. The prevalence of overweight and obesity among all patients ages 8 to 12 years without any exclusion criteria in the UTSW and Research Networks was also calculated.

Results

Of the 4,651,992 patients in the UTSW Network, 309,404 were identified as 8 to 12 years of age (Figure 1). Of the 106,509,570 patients in the Research Network, 4,791,875 were identified as 8 to 12 years of age (Figure 2). 273,260 patients from the UTSW Network met inclusion and exclusion criteria with 52.5% male and 4,288,606 patients from the Research Network met inclusion and exclusion criteria with 51.9% male. The overweight and obese, and non-overweight cohorts were separated into groups based on a diagnosis of dyspnea and gender (Table 2). Mean age and standard deviation for both the overweight and obese cohort and the non-overweight cohort was 10 ± 1 years. Being diagnosed as overweight and obese was associated with an increased risk of a diagnosis of dyspnea among all patients in the UTSW Network (RR 1.81 [95% CI 1.60-2.04]; p<0.001) and Research Network (RR 2.70 [95% CI 2.65-2.75]; p<0.001) (Table 3). In the UTSW Network, this risk was greater for females (RR 2.17 [95% CI 1.83-2.58]; p<0.001) than males (RR 1.67 [95% CI 1.42-1.97]; p <0.001). The risk among females (RR 2.71 [95% CI 2.65-2.78]; p<0.001) and males (RR 2.68 [95% CI 2.62-2.75]; p<0.001) in the Research Network was more similar. The prevalence of overweight and obesity among all patients 8 to 12 years of age without any exclusions in the UTSW and Research Networks are displayed in Table 4. In both Networks, the prevalence of overweight and obesity was more common among males than females.

Figure 1.

Figure 1.

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Diagram describing the selection of patients for analysis from the TriNetX UTSW Network was determined by age, and exclusion and inclusion criteria. BMI: body mass index; UTSW: University of Texas Southwestern Medical Center.

Figure 2.

Figure 2.

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Diagram describing the selection of patients for analysis from the Multinational Research Network was determined by age, and exclusion and inclusion criteria. BMI: body mass index.

Table 2:

Overweight and obese and non-overweight patients in the UTSW TriNetX database were categorized based on a diagnosis of dyspnea and gender. Data are presented with the number of patients and their percentage of the total in parentheses. Percentages of males and females within each Network are also shown.

UTSW Network 273260 143,480 (52.5%) 129,690 (47.5%)
Non-overweight without dyspnea 260,730 (95.4%) 136,470 (95.1%) 124,160 (95.7%)
Non-overweight with dyspnea 7,150 (2.6%) 4,200 (2.9%) 2,950 (2.3%)
Overweight and obese without dyspnea 5,120 (1.9%) 2,670 (1.9%) 2,450 (1.9%)
Overweight and obese with dyspnea 290 (0.1%) 140 (0.1%) 130 (0.1%)
Research Network 4288606 2,224,658 (51.9%) 2,060,474 (48.0%)
Non-overweight without dyspnea 3,989,521 (93.0%) 2,068,069 (93.0%) 1,918,112 (93.1%)
Non-overweight with dyspnea 105,207 (2.5%) 55,775 (2.5%) 49,422 (2.4%)
Overweight and obese without dyspnea 180,437 (4.2%) 93,712 (4.2%) 86,606 (4.2%)
Overweight and obese with dyspnea 13,441 (0.3%) 7,102 (0.3%) 6,334 (0.3%)
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UTSW: University of Texas Southwestern Medical Center.

Table 3:

Risk ratios for the association between overweight and obesity and dyspnea were calculated for patients in both UTSW and Global TriNetX databases.

UTSW Network
Risk Ratio 1.81 1.67 2.17
Confidence Interval 1.60 – 2.04 1.42 – 1.97 1.83 – 2.58
P-value <0.001 <0.001 <0.001
Research Network
Risk Ratio 2.7 2.68 2.71
Confidence Interval 2.65 – 2.75 2.62 – 2.75 2.65 – 2.78
P-value <0.001 <0.001 <0.001
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UTSW: University of Texas Southwestern Medical Center.

Table 4:

The prevalence of overweight and obesity without any exclusion criteria was calculated for all patients and for each gender in both UTSW and Research Networks.

UTSW Network
All overweight and obese patients ages 8-12 8,950 4,850 4,100
All patients ages 8-12 309,404 164,915 144,378
Prevalence 2.89% 2.94% 2.84%
Research Network
All overweight and obese patients ages 8-12 277,689 149,046 128,501
All patients ages 8-12 4,791,875 2,519,887 2,268,415
Prevalence 5.79% 5.91% 5.66%
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UTSW: University of Texas Southwestern Medical Center.

Discussion

This retrospective cohort study demonstrates that having a diagnosis of overweight and obesity significantly increases the likelihood for having a diagnosis of dyspnea in children without other significant pulmonary and cardiac comorbidities. This risk was higher for females when compared to males, especially for those females in the UTSW Network. Thus, clinicians should include overweight and obesity as part of their differential diagnosis for dyspnea and could consider it as an independent cause when other etiologies have been appropriately excluded.

To the best of our knowledge, this is the first study to demonstrate that diagnoses of overweight and obesity and dyspnea are associated in children who do not have another major medical condition likely to explain their diagnosis of dyspnea. This is in keeping with previous studies that identified obesity as a risk factor for developing dyspnea in children (Scholtens et al., 2009) and reporting dyspnea in adults (Sin et al., 2002), although these studies did not exclude patients with significant pulmonary and cardiac comorbidities. A study of pediatric patients with asthma also found that obese patients were more likely to report dyspnea than their non-obese peers (Sah et al., 2012).

Several physiological, neurophysiological, and psychophysiological mechanisms have been proposed to explain the relationship between overweight and obesity and dyspnea in otherwise healthy individuals. A proposed physiologic explanation suggests changes in chest and abdominal fat distribution lead to altered respiratory mechanics and an increased oxygen uptake and metabolic cost of exercise (Bhammar and Babb, 2021). Another proposed physiologic mechanism is that some obese patients have become more sedentary, thus lowering their cardiorespiratory fitness, requiring greater effort to perform physical exercise, and more quickly triggering sensations of dyspnea (Parshall et al., 2012). Proposed neuropsychological and psychophysiological mechanisms include increased perception of dyspnea through changes in mechanical and chemical afferent feedback from the respiratory system, alterations in the efferent signals from the central respiratory control center, and modulation of perception based on emotions, past experience, and attention to sensation (Parshall et al, 2012; Scano et al., 2010; el-Manshawi et al.,1986; Chan et al., 2012; Tsai et al., 2013; von Leupoldt et al., 2011).In addition, our study showed that the risk of dyspnea in overweight and obese females is higher than for overweight and obese males. Similar results have been reported by Skoczyński and his colleges who found women with a higher BMI had a higher rate of dyspnea (Skoczyński et al., 2019).In children, the reason for this finding remains unclear. The etiology is likely multifactorial, but may be a result of smaller lung volumes, hormonal differences, or higher percentages of body fat mass in central body regions present in females. Given the complexity and variability of dyspnea perception, multiple mechanisms likely contribute to the sensation of dyspnea (Parshall et al., 2012). More research is needed to further elucidate the relationships between these underlying mechanisms in obese patients, especially among pediatric patients where limited evidence is available.

Although our study does not provide information about causality, it does provide further evidence that obesity and dyspnea are related, even independent of other dyspnea-inducing comorbid conditions. When other causes of dyspnea have been excluded through appropriate testing, clinicians could consider overweight and obesity as an independent risk factor for dyspnea. Acknowledging this relationship could help clinicians feel more comfortable attributing dyspnea to obesity, thus reducing overdiagnosis and overtreatment of medical conditions that have already been excluded, such as asthma. As the number of overweight and obese patients grows, physicians should consider asking these patients about dyspnea since dyspnea can cause unseen suffering and worse quality of life (Parshall et al., 2012).

A secondary finding of this study was that the prevalence of all patients with overweight and obesity without any exclusion criteria in the TriNetX UTSW and Research Networks was 2.89% and 5.79%, respectively. Our findings are much lower than the National Center for Health Statistics reported prevalence of 35.4% (Fryar et al., 2020). Previous studies have also found that overweight and obesity are underdiagnosed and under-coded in EMR in both adults and children (Mattar et al., 2017; Otero et al., 2011). Because this underdiagnosis of overweight and obesity has been observed in previous studies, the results of this study likely underestimated the risk for overweight and obese patients to be diagnosed with dyspnea. In addition to providing more accurate EMR, previous research has also shown that documentation of obesity as a medical problem improves physician attention to a patient’s weight and increases the likelihood that a patient receives exercise and diet counseling (Mattar et al., 2017; Brown et al., 2006), which can also lower the risk for adverse cardiovascular events. More accurate diagnosis and coding could also make future studies using large databases such as TriNetX more accurate and provide opportunities for improved data mining.

Our study was limited by the accuracy of the diagnostic codes and information provided from HCO to the TriNetX database, as evidenced by the low prevalence of overweight and obesity in the UTSW and Research Networks. There is not a way to determine if the differences in findings of the Research and UTSW networks are due to characteristics of the populations included or if they are due to variability in the data reported by HCOs to TriNetX. Regardless, our findings are consistent with previous studies that also reported that dyspnea is a common symptom of obesity. An additional limitation for this study is that there is a possibility that dyspnea could be attributed to an infection such as an acute upper respiratory tract infection, pneumonia, or SARS-CoV-2. These conditions were not excluded from this study since they are very common diagnoses that dramatically reduced the number of eligible patients. While some limitations are inherent to the TriNetX database, our study highlights the benefit of this dynamic resource. TriNetX could be especially useful to quickly gain a broad understanding of associations between diagnoses and patient characteristics in a frequently updated and user-friendly environment. TriNetX may be particularly beneficial for feasibility studies or exploring associations of rare diseases. Moreover, further research is needed to better understand the relationship between overweight and obesity and dyspnea in otherwise healthy pediatric patients. Determining the etiology could provide new insights into how clinicians should discuss this issue with their patients and propose potential mitigating interventions to improve the lives of their patients.

Conclusions

In summary, this is the first study to use real-world, “big data” to examine whether children with diagnoses of overweight and obesity are more likely to have a diagnosis of dyspnea. Our findings demonstrate that the diagnoses of overweight and obesity and dyspnea are associated in children who do not have another major medical condition likely to explain their diagnosis of dyspnea. These findings have important clinical implications and suggest that clinicians could consider overweight and obesity as an independent risk factor dyspnea once other etiologies are excluded. Lastly, this study also highlights the need for accurate coding and diagnosis in the EMR, especially among HCOs contributing to large databases, such as TriNetX.

Highlights.

  • Patients with overweight and obesity had a significantly higher risk of dyspnea.

  • The risk of obesity was found to be higher in females compared with male.

  • Clinicians should consider obesity as an independent risk factor for dyspnea in pediatric patients.

FUNDING

Supported in part by National Institutes of Health (R01 HL136643, K99 HL164957, R38 HL150214), King Charitable Foundation Trust, Susan Lay Atwell Gift for Pulmonary Research, Cain Foundation, and Texas Health Presbyterian Hospital Dallas.

Footnotes

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DISCLOSURES

No conflicts of interest, financial or otherwise, are declared by the authors.

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