Exploring Adipose Tissue Behavior in CT: Impact of Age, Sex, and Contrast Media on Body Composition, Liver and Skeletal Muscle

Objectives: To evaluate the impact of contrast phase, age, and sex on CT-derived body composition metrics—specifically attenuation and volume of subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT), liver, and skeletal muscle. The potential of the proportion of muscle voxels below 0 Hounsfield units (HU) as a surrogate for fatty infiltration was also explored. Materials and Methods: A retrospective analysis of 866 multiphasic abdominal CT scans (non-enhanced [NE], arterial [ART], portal venous [PV]) from 2012 to 2022 was performed. Segmentation of SAT, VAT, liver, and skeletal muscle was conducted using the AI-based TotalSegmentator. Wilcoxon signed-rank tests and Bland–Altman analysis (mean bias and 95% limits of agreement) were applied to assess contrast-related effects; Spearman’s correlation coefficient was used to assess demographic associations. Results: Significant variation in attenuation and volume of SAT, VAT, and muscle was observed across contrast phases (p < 0.001). SAT attenuation was higher in NE and PV than in ART, while VAT attenuation was highest in PV. SAT volume increased and VAT volume decreased in contrast-enhanced phases. Attenuation and volume showed strong inter-phase correlation (ρ > 0.9). VAT attenuation was significantly higher in females, whereas VAT volume was significantly greater in males. VAT volume negatively correlated with liver attenuation (ρ = −0.33). Muscle voxels <0 HU were significantly reduced in contrast-enhanced scans. Conclusion: Contrast phase, age, and sex significantly influence CT-based body composition parameters. These confounding factors should be considered when using quantitative imaging biomarkers in clinical and research settings.