AJCN EB Program 2010 Early Registration
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Purchase Article
Right arrow View Shopping Cart
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Guillaume, M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Guillaume, M.
Agricola
Right arrow Articles by Guillaume, M.
American Journal of Clinical Nutrition, Vol. 70, No. 1, 126S-130S, July 1999
© 1999 American Society for Clinical Nutrition

Supplements

Defining obesity in childhood: current practice1,2

Michèle Guillaume

1 From the Department of Preventive Medicine, Observatoire de la Santé, Bastogne, Belgium.


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
A survey of information from 26 countries was performed to examine the methods, cutoff points, and reference materials used to define obesity in childhood and adolescence. The body mass index (in kg/m2) was used frequently, as well as several other methods. Reference materials used were often based on national surveys, although reference data from other countries were sometimes used. The data presented was often insufficient to judge the representativeness of the reference material. Cutoff points varied considerably. Available data allow neither a meaningful international estimation of the prevalence of obesity nor international comparisons. Although associated with considerable problems, this situation can be improved with an international consensus which, by necessity, will be riddled with uncertainties and compromises.

Key Words: Obesity • children • adolescents • body mass index • International Obesity Task Force


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Although the long-term effect of overweight and obesity on morbidity and mortality in children has not yet been well documented, several studies suggest that obesity in childhood is followed by serious consequences in adulthood 1,2. Childhood obesity often tracks into adulthood (3–5). Epidemiologic studies of long duration are needed to explore these issues more thoroughly.

Obesity is defined as an excess of body fat mass. Body mass index (BMI; in kg/m2) has achieved international acceptance as a standard for the assessment of obesity in adults and correlates with body fat (r = 0.7–0.8) (6). In children, factors such as growth make definitions more complex. Therefore, different methods have been used to calculate prevalence of childhood obesity internationally.

The working group on childhood obesity of the International Obesity Task Force (IOTF) proposed to determine the prevalence of obesity in children and adolescents worldwide and to analyze secular trends internationally. This article is an analysis of the application of different standards using data from different countries. The results indicate clearly that an internationally applicable standard is needed to allow comparisons.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Data were selected from 30 countries in which published or unpublished data were available. Useful information was obtained from 26 of these countries. The selection procedure for the populations studied in these reports as well as the methods used for measurements are found in references (7–31) or in unpublished communications.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
BMI has been used in many countries, although cutoff points used vary between the 85th and 97th percentile (Table 1Go). Weight-for-height, as well as weight/ideal weight are also often used, the latter with a cutoff limit of >120%. The use of skinfold thicknesses and weight:height3 was reported by several countries.


View this table:
[in this window]
[in a new window]
  		TABLE 1. Indexes and cutoff points used in different countries to define obesity1,
 
To define obesity, a reference population is needed (Table 2Go). Many countries have collected their own reference material. In other countries American (23), British (20), and French (3) as well as the Tanner and Whitehouse (32) standards have been used as references.


View this table:
[in this window]
[in a new window]
  		TABLE 2. Standards from different populations used in different countries to determine the prevalence of obesity
 
The 85th percentile limit of reference standards at different ages from Australia (30), the United Kingdom (20), and the United States (23) are shown in Figure 1Go. The Australian and US curves overlap and the British data are slightly lower. Such apparently small differences may, however, be important. Data from children aged >10 y from Australia and >8 y from the United Kingdom appear to be systematically lower than those from US children. These differences appear to increase with age.



View larger version (11K):
[in this window]
[in a new window]
  		FIGURE 1. Comparison of the 85th percentile cutoff points of BMI for the United States ({blacktriangleup}) (23), United Kingdom (•) (20), and Australia ({blacksquare}) (30).

 
Even small differences in BMI cutoff values may produce widely different estimates of the prevalence of obesity when applied to other countries. This is illustrated in Figure 2Go with examples from 6 countries, where the 85th percentile BMI-for-age of the US (23) and the UK (20) standards were applied. For the youngest children (aged 6–8 y), the UK standard gave 0–4% lower prevalence estimates than did the US standard. After age 9 y, the differences were reversed; 3–13% higher prevalence estimates of obesity were obtained when the UK standards were used as the reference compared with the US standards.



View larger version (34K):
[in this window]
[in a new window]
  		FIGURE 2. Difference in prevalence of obesity when applying the UK reference standard (20) compared with the US reference standard (23).

 
Discrepancies in the prevalence of obesity may be even greater if different indexes are used (Table 3Go). In Hungary, when the 90th percentile of triceps skinfold thickness of the Tanner and Whitehouse (32) reference was used to define obesity, the prevalence was {approx}3% higher than when the 90th percentile of the BMI of the local population was used. In Argentina, when the 85th percentile of the US first National Health and Nutrition Examination Survey (NHANES I; 23) was used, the prevalence of obesity was more than double the prevalence obtained when the cutoff of >120% of weight-for-height of a local reference population was used. More dramatic differences in the prevalence of obesity were obtained when the cutoff of the local >120% weight-for-height, the US NHANES I (23) and the UK (20) reference standards were applied to the Singaporean data from children (Figure 3Go).


View this table:
[in this window]
[in a new window]
  		TABLE 3. Prevalence of obesity in Hungary and Argentina as measured with different indexes
 


View larger version (25K):
[in this window]
[in a new window]
  		FIGURE 3. The prevalence of obesity in Singaporean children when using different reference standards: {square}, Singaporean standard, weight-for-height >120%; {blacksquare}, US standard (23), BMI above the 85th percentile; and {blacksquare}, UK standard (20), BMI above the 85th percentile.

 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
This survey of data on childhood obesity examined measurements of obesity, reference material used in different countries, and the use of various methods for identifying the prevalence of obesity in children.

When estimating obesity in children, various means have been used to adjust the effect of body weight on height. Both age and sex affect such adjustments, resulting in complex relations (33) that may also show local variations. The information now available suggests that BMI is used frequently, particularly in Europe. Data collected before 1990 indicate that BMI was less frequently used at that time (34). Furthermore, more European centers now report data on prevalence of obesity in children. The organization and activities of a European Child Obesity Group might have helped to accomplish these changes (35). In North and South America several indexes have been used, which may reflect a lack of consensus. In Latin America and Asia weight-for-height is often used, except in Japan, where BMI is reported.

The definition of cutoff points for overweight and obesity vary from above the 85th to above the 97th percentiles. Nomenclature also varies; the 97th percentile of BMI is called obesity in Netherlands (18, 19) and super-obesity in France (3).

Most surveys relied on local populations with a defined cutoff point above which obesity was considered to be present. Little information was provided on sample size, sample selection, representation, or refusal rates.

The data available for estimates of prevalence are far from complete, and represent only the responses to a limited inquiry. Nevertheless, the results seem to provide some useful information. Different methods, cutoff points, and reference material were used. This makes international comparisons of the prevalence of childhood obesity of limited value at present. Clearly an international consensus on definitions is needed.

The definition of childhood and adolescent obesity remains unclear. In adults, the comorbidities of obesity can be used to establish cutoff points. Subgrouping into central and peripheral obesity is useful because of the higher risks associated with the former (36). However, morbidity occurs less frequently in children, and the role of body fat distribution has not been studied thoroughly (37–39). The psychologic problems associated with childhood obesity caused by frequent exclusion from group activities are also important to consider. Because discrimination (40, 41) as well as metabolic comorbidities (39–42) follow BMI closely, use of BMI may be justified when screening a population. How well BMI measures body fat mass in children may become a greater problem when different populations are screened and compared.

The definition of obesity in childhood and adolescence is clearly an important question but is hampered by several difficulties. This question should be resolved by consensus and compromise so that we can begin to examine the prevalence of childhood obesity worldwide. In addition, further screening and follow-up of populations is needed to improve the basis on which future decisions will be made.


   FOOTNOTES
 
2 Address reprint requests to M Guillaume, Department of Preventive Medicine, Observatoire de la Santé, Province of Luxembourg, Chaussée d'Houffalize, 1bis, 660 Bastogne, Brussels, Belgium. E-mail: m.p.t{at}skynet.be


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Mossberg HO. 40-year follow-up of overweight children. Lancet 1989;2:491–3.[Medline]
  2. Must A, Jacques PF, Dallal GE, Bajema CJ, Dietz WH. Long-term morbidity and mortality of overweight adolescents. A follow-up of the Harvard Growth Study from 1922 to 1935. N Engl J Med 1992; 327:1350–5.[Abstract]
  3. Rolland-Cachera M-F, Deheeger M, Guilloud-Bataille M, Avons P, Patois E, Sempe M. Tracking the development of adiposity from one month of age to adulthood. Ann Hum Biol 1987;14:219–29.[Medline]
  4. Fisch RO, Bilek MK, Ulstrom R. Obesity and leanness at birth and their relationship to body habitus in later childhood. Pediatrics 1975;56:521–8.[Abstract/Free Full Text]
  5. Guo SS, Roche AF, Chumlea WC, Gardner JD, Siervogel RM. The predictive value of childhood body mass index values for overweight at age 35 y. Am J Clin Nutr 1994;59:810–9.[Abstract/Free Full Text]
  6. Epstein FH, Higgins M. Epidemiology of obesity. In: Björntorp P, Brodoff BN, eds. Obesity. Philadelphia: JB Lippincott Co, 1992: 330–42.
  7. Vercauteren M. Evolution seculaire et normes de croissance chez les enfants belges. (Secular growth changes of Belgian children) Bull Soc R Belge Anthropol Prehist 1984;95:109–23 (in French).
  8. Guillaume M, Lapidus L, Beckers F, Lambert A, Björntorp P. Familial trends of obesity through three generations: The Belgian Luxembourg Child Study. Int J Obes 1995;19(suppl):5–9.
  9. Thomsen BL, Ekstrom C, Sorensen TIA. Changes in the distribution of weight, height and body mass index at ages 7 to 14 years in a population of Danish boys born 1930 through 1966. Int J Obes 1995;19(suppl).
  10. Nuutinen EM, Turtinen J, Pokka T, et al. Obesity in children, adolescents and young adults. Ann Med 1991;23:41–6.[Medline]
  11. Michel U, Riechers B. Cardiovascular risk factors in school children. J Am Coll Nutr 1994;11(suppl):36–40.[Abstract]
  12. Mamalakis G, Kafatos A. Prevalence of obesity in Greece. Int J Obes 1996;20:488–92.
  13. Maffeis C, Schutz Y, Piccoli R, Gonfiantini E, Pinelli L. Prevalence of obesity in children in North-East Italy. Int J Obes 1993;17:287–94.
  14. Luciano A, Bressan F, Zoppi G. Body mass index reference curves for children aged 3–19 years from Verona, Italy. Eur J Clin Nutr 1997;51:6–10.[Medline]
  15. Elcarte-Lopez R, Villa-Elizaga I, Sada-Goni J, et al. Estudio de Navarra (PECNA). Prevalencia de hipertension arterial, hiperlipidemia y obesidad en la poblacion infanto-juvenil de Navarra. (Study of Navarra. Prevalence of arterial hypertension, hyperlipidemia and obesity in children and adolescents. Association of risk factors.) Associacion de estos factores de riesgo. Ann Esp Pediatr 1993;38: 428–36 (in Spanish).
  16. Flodmark CE, Ohlsson T, Ryden O, Sveger T. Prevention of progression to severe obesity in a group of obese school children treated with family therapy. Pediatrics 1993;91:880–4.[Abstract/Free Full Text]
  17. Cenerud L, Lindgren GW. Secular changes in height and weight of Stockholm schoolchildren born in 1933, 1943, 1953 and 1963. Ann Hum Biol 1991;18:497–505.[Medline]
  18. Sper-van der Wekkes J, Meulmeester JF, Radder JJ, Verloove-Vanhorick SP, Schalk-van der Weide Y. Peilingen in de jeugdgezondheidszorg: PGO-peiling 1992/1993. (Findings from preventive health studies in children in 1992–1993.) Wageningen, Netherlands: TNO Preventie en Gezondheid, report no. 94.091, 1994 (in Dutch).
  19. Brugman E, Meulmeester JF, van der Wekkes J, Beuker RJ, Radder JJ. Peilingen in the jeugdgezondheidszorg: PGO-peiling 1993/1994. (Findings from preventive health studies in children in 1993–1994.) Wageningen, Netherlands: TNO Preventie en Gezondheid, 1995 (in Dutch). (Report no. 95.061.)
  20. Cole TJ, Freeman JU, Preece MA. Body mass index reference curves for the UK, 1990. Arch Dis Child 1995;73:25–9.[Abstract/Free Full Text]
  21. White EM, Wilson AC, Greene SA, et al. Body mass index centile charts to assess fatness of British children. Arch Dis Child 1995; 72:38–41.[Abstract/Free Full Text]
  22. Whincup PH, Cook DG, Adshead F, et al. Cardiovascular risk factors in British children from towns with widely differing adult cardiovascular mortality. BMJ 1996;313:79–84.[Abstract/Free Full Text]
  23. Must A, Dallal GE, Dietz WH. Reference data for obesity: 85th and 95th percentiles of body mass index (wt/ht2) and triceps skinfold thickness. Am J Clin Nutr 1991;53:839–46.[Abstract/Free Full Text]
  24. Frerichs R, Webber L, Srinivasan S, Berenson G. Relation of serum lipids and lipoproteins to obesity and sexual maturity in white and black children. Am J Epidemiol 1978;108:486–96.[Abstract/Free Full Text]
  25. Hamill PVV, Drizd TA, Johnson CL, Reed RB, Roche AF. NCHS growth curves for children birth-18 years. Washington, DC: National Center for Health Statistics, 1978. [DHEW publication no. (PHS) 78-1650.]
  26. Leung SSF, Lau JTF, Tse LY, Oppenheimer SJ. Weight-for-age and weight for height references for Hong-Kong children from birth to 18 years. J Paediatr Child Health 1996;32:103–9.[Medline]
  27. Sirai K, Shinomiya M, Umezono T, et al. Incidence of childhood obesity over the last ten years in Japan. Diabetes Res Clin Practice 1990;10(suppl):65–70.[Medline]
  28. Kao MT, Wong WY, Tsang MS, Lee LY, Tse MC. Height and weight as measurement of nutritional status of Taiwanese in 1986–1988. Chin Nutr Soc 1991;16:63–84.
  29. Mo-Suwan L, Geater AF. Risk factors for childhood obesity in a transitional society in Thailand. Int J Obes Relat Metab Disord 1996;20:697–703.[Medline]
  30. Lazarus R, Baur L, Webb K, Blyth F, Gliksman M. Recommended body mass index cut off values for overweight screening programmes in Australian children and adolescents: comparisons with North American values. J Paediatr Child Health 1995;31:143–7.[Medline]
  31. Al-Nuaim AR, Bamgboye EA, Al-Herbish A. The pattern of growth and obesity in Saudi Arabian male school children. Int J Obes Relat Metab Disord 1996;20:1000–5.[Medline]
  32. Tanner JM, Whitehouse RH. Revised standards for triceps and subscapular skinfolds in British children. Arch Dis Child 1975;50:142–5.[Abstract/Free Full Text]
  33. Fung KP, Lee J, Lau SP, Chow OKW, Wong TW, Davis DP. Properties and clinical implications of body mass indices. Arch Dis Child 1990;65:516–9.[Abstract/Free Full Text]
  34. Frelut M-L, Cathelineau L, Bihain B-E, Navarro J. Prévalence de l'obésité infantile dans le monde. Quelle évolution? (Changing trends in the prevalence of childhood obesity world-wide.) Med Nutr 1995;31:293–7 (in French).
  35. Poskitt EME, European Childhood Obesity Group. Committee report. Defining childhood obesity: the relative body mass index (BMI). Acta Paediatr 1995;84:961–3.[Medline]
  36. World Health Organization. Obesity: preventing and managing the global epidemic. Report of a WHO consultation on obesity, Geneva, 3–5 June 1997. Geneva: WHO, 1998 (WHO/NUT/NCD/98.1).
  37. Fox K, Peters D, Armstrong N, Sharpe P, Bell M. Abdominal fat deposition in 11-year-old-children. Int J Obes 1993;17:11–6.
  38. Brambiller P. Peripheral and abdominal adiposity in childhood obesity. Int J Obes Relat Metab Disord 1994;18:795–800.[Medline]
  39. Guillaume M, Lapidus L, Beckers F, Lambert A, Björntorp P. Cardiovascular risk factors in children from the Belgian province of Luxembourg. The Belgian Luxembourg Child Study. Am J Epidemiol 1996;144:867–80.[Abstract/Free Full Text]
  40. Dietz WH. Childhood obesity. In: Björntorp P, Brodoff BN, eds. Obesity. Philadelphia: JB Lippincott Co, 1992:606–8.
  41. Hill AJ, Silver EK. Fat, friendless and unhealthy: 9 year old children's perception of body shape stereotypes. Int J Obes Relat Metab Disord 1995;19:423–30.[Medline]
  42. Lauer RN, Connor WE. Coronary heart disease risk factors in school children: The Muscatine Study. J Pediatr 1975;86:697–706.[Medline]



This article has been cited by other articles:


Home page
 PediatricsHome page
Y. Wang
Is Obesity Associated With Early Sexual Maturation? A Comparison of the Association in American Boys Versus Girls
Pediatrics, November 1, 2002; 110(5): 903 - 910.
[Abstract] [Full Text] [PDF]

Home page
 Am. J. Clin. Nutr.Home page
Y. Wang, C. Monteiro, and B. M Popkin
Trends of obesity and underweight in older children and adolescents in the United States, Brazil, China, and Russia
Am. J. Clinical Nutrition, June 1, 2002; 75(6): 971 - 977.
[Abstract] [Full Text] [PDF]

Home page
 BMJHome page
L. Edmunds, E. Waters, and E. J Elliott
Evidence based paediatrics: Evidence based management of childhood obesity
BMJ, October 20, 2001; 323(7318): 916 - 919.
[Full Text] [PDF]

Home page
 Int J EpidemiolHome page
Y. Wang
Cross-national comparison of childhood obesity: the epidemic and the relationship between obesity and socioeconomic status
Int. J. Epidemiol., October 1, 2001; 30(5): 1129 - 1136.
[Abstract] [Full Text] [PDF]

Home page
 Am. J. Clin. Nutr.Home page
W. H Dietz and M. C Bellizzi
Introduction: the use of body mass index to assess obesity in children
Am. J. Clinical Nutrition, July 1, 1999; 70 (1): 123S - 125S.
[Abstract] [Full Text] [PDF]

Home page
 Am. J. Clin. Nutr.Home page
M. Franklin
Comparison of weight and height relations in boys from 4 countries
Am. J. Clinical Nutrition, July 1, 1999; 70 (1): 157S - 162S.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Purchase Article
Right arrow View Shopping Cart
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Guillaume, M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Guillaume, M.
Agricola
Right arrow Articles by Guillaume, M.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS