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The Use of the Body Mass

Index in Under 18 year olds


Dr. David McCarthy RNutr
Institute of
Health Research & Policy
London Metropolitan University
28
th
March 2004
Body Mass Index (BMI)
in adults - affected minimally by age
popular, quick, use fixed cut-off points
in children - greatly affected by age
Drawbacks of BMI in children
Age-dependent
Correlates with both fat
mass and fat-free mass
Low sensitivity
no indication of body
fat distribution
Cannot identify secular
trends
BMI
40 30 20 10
F
a
t

M
a
s
s

(
k
g
)
40
30
20
10
0
Correlation of BMI with Fat Mass (kg)
r
2
= 0.763, P<0.0001
16-18 year olds
BMI
40 30 20 10
F
a
t

F
r
e
e

M
a
s
s

(
k
g
)
80
70
60
50
40
30
Correlation of BMI with Fat Free Mass (kg)
r
2
= 0.514, P<0.0001
16-18 year olds
Cut-off points
US 85
th
and 95
th
centiles
UK 91
st
and 98
th
centiles
IOTF centiles relating to BMI of 25
and 30 at age 18 years
IOTF obese
IOTF overweight
Childhood prevalence
in the UK
Obese 17% (BMI >95
th
centile)
Overweight 31% (BMI >85
th
centile)
Source: Reilly et al. 1999
Assessment requirements
in children
Simple measurement technique
Strongly related to morbidity or risk
(CHD)
Biological/clinical definition
Avoid misclassification
Waist circumference
in adults
Indicator of intraabdominal fat
related to risk for NIDDM,
hypertension and CVD
waist:hip and waist:height ratios
Central body fat
accumulation in children
Intra-abdominal
adipose tissue
Subcutaneous
abdominal adipose
tissue
assessed by girth
and skinfold
measurements
Is waist circumference in
children linked to risk?
WC related to an adverse atherogenic
lipoprotein profile in 12-14 year olds
(Flodmark et al. 1994)
WC related to adverse insulin
concentration in 5-17 year olds
(Bogalusa Heart Study, Freeman et al. 1999)
Waist circumference
and blood pressure
Jarrett, McCarthy et al. (unpublished
observations, 2002), 4 and 5 year olds)
The Metabolic Syndrome
WC percentile charts
in children
Italian children (Zannolli & Morgese
1996)
Spanish children (Moreno et al. 1999)
Cuban children (Martinez et al. 1994)
British children (McCarthy et al. 2000)
Waist circumference measurement
Midway between the 10
th
rib
and the iliac crest
WHO standard method
Used by :
McCarthy et al. 2000
Freedman et al. 1999
Moreno et al. 1999
Waist circumference measurement
continued.
At the level of the umbilicus
Used for the waist circumference
percentiles in Italian children,
Zanolli et al. 1996
UK children's study
8355 children
aged 5-17 years
mean and SD for waist
circumference
smoothed percentile curves
constructed using the LMS method
(Cole 1990)
4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Age (years)
40
50
60
70
80
W
a
i
s
t

c
i
r
c
u
m
f
e
r
e
n
c
e

(
c
m
)
Boys
Girls
Waist in children
n, 8355
McCarthy et al. 2001, EJCN
Development of WC centile charts for the UK children
3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Age (years)
40
45
50
55
60
65
70
75
80
85
90
95
100
W
a
i
s
t

c
i
r
c
u
m
f
e
r
e
n
c
e

(
c
m
)
40
45
50
55
60
65
70
75
80
85
90
95
100
99.6
98
91
75
50
25
9
2
0.4
Boys 3-17 y
D.McCarthy2001
3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Age (years)
40
45
50
55
60
65
70
75
80
85
90
95
100
W
a
i
s
t

c
i
r
c
u
m
f
e
r
e
n
c
e

(
c
m
)
40
45
50
55
60
65
70
75
80
85
90
95
100
99.6
98
91
75
50
25
9
2
0.4
Girls 3-17 y
D.McCarthy2001
What about clothing effects?
Preferable to measure
over skin
need to take account of
vest, T-shirt or school
shirt
subtract 0.5 cm from
reading
problem in measuring
over tunics
Waist Girth WsGr
70 60 50 40
B
M
I
22
20
18
16
14
12
Boys aged 6.0-6.99 y
p<0.01
r
2
=0.689
n=349
Waist circumference vs BMI
Waist Girth WsGr
80 70 60 50 40
B
M
I
24
22
20
18
16
14
12
10
Girls aged 6.0-6.99 y
p<0.01
r
2
=0.716
n=400
Waist circumference vs BMI
BMI-WC relationship
Subject Age BMI WC BMI %ile WC %ile
(y) (cm)
A 7.7 15.2 48 ~50th <9th
B 7.5 15.3 65 ~50th >98th
C 7.1 19.1 53 >91st ~50th
D 7.1 20.0 67 >98th >99.6th
BMI-WC relationship
Subject Age BMI WC BMI %ile WC %ile
(y) (cm)
A 14 19.3 66 ~50th ~40th
B 14 19.3 85 ~50th ~98th
C 14 21.7 65 ~85th ~30th
D 14 28 94 >98th >98th
Source - NDNS Young People aged 4 to 18 yrs, Gregory & Lowe, 2000)
Has upper body fatness
increased in British children?
Comparison of data collected
10 and 20 years apart
BSI and NDN surveys
10 11 12 13 14 15 16 17
Age group (years)
58
62
66
70
74
78
82
W
a
i
s
t

c
i
r
c
u
m
f
e
r
e
n
c
e

(
c
m
)
**
**
**
**
**
**
**
**
**
**
**
**
McCarthy et al. 2003. BMJ 326: 624
NDNS boys
NDNS girls
BSI boys
BSI girls
10 11 12 13 14 15 16
Age group (years)
17
18
19
20
21
22
23
24
B
o
d
y

M
a
s
s

I
n
d
e
x

(
k
g
/
m
2
)
*
*
*
+
*
*
*
*
*
*
*
*
McCarthy et al. 2003. BMJ 326: 624
NDNS girls
NDNS boys
BSI girls
BSI boys
Changes over 10-20 years in overweight and obesity based
on BMI and waist circumference in British children aged 11-
16 years. Values are % exceeding 91
st
centile (98
th
centile)
% prevalence of overweight % change
(obesity) over time
BSI 1977/87 NDNS 1997
Male Female Male Female Male Female
BMI 7.7 5.9 20.6 17.3 12.9 11.4
(3.3) (1.6) (10.0) (8.3) (6.8) (6.6)
WC 8.7 8.8 28.5 38.1 1 9.8 29.3
(3.3) (3.1) (13.8) (17.1) (10.7) (14.5)
McCarthy et al. 2003. BMJ 326: 624
Changes over 10-20 years in mean BMI and waist
circumference in British children aged 11-16 years.
Mean SD Score (SD) Mean increase
over time (SE)
BSI 1977/87 NDNS 1997
Male Female Male Female Male Female
BMI -0.05 -0.15 0.42 0.38 0.47 0.53
(1.02) (0.99) (1.13) (1.09) (0.06) (0.06)
WC 0.00 0.00 0.84 1.02 0.84 1.02
(0.99) (1.00) (1.02) (1.33) (0.06) (0.06)
McCarthy et al. 2003. BMJ 326: 624
How should I use the WC
percentile charts?
In conjunction with BMI centile charts
as a second line point of reference for
referral
routinely
epidemiology
research
Further issues
Cut-off points yet to be linked to risk or
Fat Mass
What effect does measurement error
have upon validity of WC percentiles?
Relationship between BMI and WC
centile
Conclusions
Waist circumference important in children
Simple technique
WC correlates with risk factors for CHD
further work required on validation of
technique
other countries could begin to develop WC
percentiles in their childhood population
Genetics Prenatal diet
Leg length?
Infant feeding
Current diet
Physical
activity
central obesity
Catch-up
growth
Acknowledgements
Karen Jarrett
Adam Collins
Prof. Tim Cole
Sandra Ellis
Pauline Emmett
Jean Golding and
the ALSPAC
team