A cross-sectional study, which identified that IAAT is inversely related to BMD. In this pediatric sample, the mean of IAAT was 4.35 cm which seems a normal value, because it was similar to another group of sedentary obese children and adolescents without non-alcoholic fat liver disease (mean value of 4.1 cm) . On the other hand, the same group of obese children and adolescents had a significant decrease of 1.6 cm after one year of exercise intervention , supporting the relevance of the sedentary lifestyle as an inclusion criteria and evidencing the potential of prolonged engagement of physical exercise in combating comorbidities related to abdominal obesity [8, 9]. The inclusion of the sedentary lifestyle was also important because there is a positive relationship between increased habitual physical activity and BMD .
Gender is an important variable related to skeletal formation. Male adolescents, more than girls, are affected by biological processes that accelerate bone development . In the final stages of adolescence, boys are taller and have a higher bone mineral density . Through childhood and adolescence, when compared to the female gender, boys have an increased likelihood of practicing sports [8, 9], which are related to bone development. Moreover, during adulthood, hormonal characteristics of male obesity may exert deleterious effects on bone microarchitecture . Therefore, the inclusion of gender as a potential confounder constitutes a methodological strength, because it indicates that IAAT is inversely related to BMD independent of this important confounder.
Agreeing with previous studies, in this sample there was a positive relationship between body weight/adiposity and BMD [11, 20]. Indeed, obese subjects, from an early age, have increased bone density, mainly due to the stress occasioned by the increased weight on bone tissue that causes deformation and, hence, leads to bone remodeling . Similarly, the same mechanical/biochemical process offers support to the idea that sports with impact are important tools in the promotion of adequate bone health in adolescents . It is noteworthy that although obesity is positively related to BMD, more recent findings suggest that bone quality is compromised in obese subjects .
On the other hand, our findings point out that body fatness distribution should be considered as a potential confounder in this relationship, because increased IAAT was inversely related to BMD, independent of general obesity. Previous studies involving anthropometric (waist-to-hip ratio)  and DXA variables (abdominal fatness in kg)  identified similar relationship patterns in children and adults, respectively.
The inverse relationship between IAAT and BMD could be based on the action of adipokines produced by adipose tissue over growth mediators related to bone development. Nemet et al.  identified, in a longitudinal design, that the practice of very high intensity physical exercise simultaneously caused a significant increase in pro-inflammatory markers (tumor necrosis factor - alpha) and a subsequent decrease in growth mediators, such as insulin-like-growth-factor-I. Similarly, the adipose tissue located in the abdominal region (mainly the visceral one) has a special role in the release of adipokines into the bloodstream . Therefore, it is possible to believe that IAAT could be a risk factor related to a harmful effect in bone remodeling and in turn to a risk factor of osteoporosis in adulthood.
Visceral adipose tissue is related to insulin resistance and insulin plays a role in the proliferation of osteoblasts. Thus, decreased insulin action may be one of the possible mechanisms by which obesity affects bone mass. In agreement, in a recent study, increased insulin concentration and HOMA-IR were considered negative predictors of bone mineral density in adolescents . However, this is a recent finding that needs further top research focusing on the understanding of the physiological common mechanisms behind this association.
Our study has positive points, such as: (i) the sample size calculation; (ii) the use of adequate techniques to measure body composition/IAAT. On the other hand, limitations should be recognized: (i) the cross-sectional design (absence of causality statements), (ii) an absence of measurements relating to the intake of calcium and vitamin D and (iii) an absence of pro-inflammatory adipokines. Moreover, there were correlations of low magnitude between BMD and IAAT, indicating that other variables are important in this relationship and, therefore, further studies are necessary to identify them.