BMJ 2000;320:1240-1243 ( 6 May )

Papers

Establishing a standard definition for child overweight and obesity worldwide: international survey

Tim J Cole, professor of medical statistics ^a,  Mary C Bellizzi, health policy officer ^b,  Katherine M Flegal, senior research scientist ^c,  William H Dietz, director ^d. 

^a Department of Epidemiology and Public Health, Institute of Child Health, London WC1N 1EH, ^b International Obesity Task Force Secretariat, London NW1 2NS, ^c National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville MD 20782, USA, ^d Division of Nutrition and Physical Activity, Centers for Disease Control and Prevention, Atlanta GA 30341-3724, USA

Correspondence to: T J Cole tim.cole{at}ich.ucl.ac.uk

	Abstract

Top Abstract Introduction Subjects and methods Results Discussion References

Objective: To develop an internationally acceptable definition of child overweight and obesity, specifying the measurement, the reference population, and the age and sex specific cut off points.
Design: International survey of six large nationally representative cross sectional growth studies.
Setting: Brazil, Great Britain, Hong Kong, the Netherlands, Singapore, and the United States.
Subjects: 97 876 males and 94 851 females from birth to 25 years of age.
Main outcome measure: Body mass index (weight/height²).
Results: For each of the surveys, centile curves were drawn that at age 18 years passed through the widely used cut off points of 25 and 30 kg/m² for adult overweight and obesity. The resulting curves were averaged to provide age and sex specific cut off points from 2-18 years.
Conclusions: The proposed cut off points, which are less arbitrary and more internationally based than current alternatives, should help to provide internationally comparable prevalence rates of overweight and obesity in children.

	Introduction

Top Abstract Introduction Subjects and methods Results Discussion References

The prevalence of child obesity is increasing rapidly worldwide.¹ It is associated with several risk factors for later heart disease and other chronic diseases including hyperlipidaemia, hyperinsulinaemia, hypertension, and early atherosclerosis.^2-4

Because of their public health importance, the trends in child obesity should be closely monitored. Trends are, however, difficult to quantify or to compare internationally, as a wide variety of definitions of child obesity are in use, and no commonly accepted standard has yet emerged. The ideal definition, based on percentage body fat, is impracticable for epidemiological use. Although less sensitive than skinfold thicknesses,⁵ the body mass index (weight/height²) is widely used in adult populations, and a cut off point of 30 kg/m² is recognised internationally as a definition of adult obesity.⁶

Body mass index in childhood changes substantially with age. ^{7 8} At birth the median is as low as 13 kg/m², increases to 17 kg/m² at age 1, decreases to 15.5 kg/m² at age 6, then increases to 21 kg/m² at age 20. Clearly a cut off point related to age is needed to define child obesity, based on the same principle at different ages, for example, using reference centiles.⁹ In the United States, the 85th and 95th centiles of body mass index for age and sex based on nationally representative survey data have been recommended as cut off points to identify overweight and obesity.¹⁰ For wider international use this definition raises two questions: why base it on data from the United States, and why use the 85th or 95th centile?

A reference population could be obtained by pooling data from several sources, if sufficiently homogeneous. A centile cut off point could in theory be identified as the point on the distribution of body mass index where the health risk of obesity starts to rise steeply. Unfortunately such a point cannot be identified with any precision: children have less disease related to obesity than adults, and the association between child obesity and adult health risk may be mediated through adult obesity, which is associated both with child obesity and adult disease.

The adult cut off points in widest usea body mass index of 25 kg/m² for overweight and 30 kg/m² for obesityare related to health risk¹ but are also convenient round numbers. A workshop organised by the International Obesity Task Force proposed that these adult cut off points be linked to body mass index centiles for children to provide child cut off points. ^{11 12} We describe the development of age and sex specific cut off points for body mass index for overweight and obesity in children, using dataset specific centiles linked to adult cut off points.

	Subjects and methods

Top Abstract Introduction Subjects and methods Results Discussion References

Subjects
We obtained data on body mass index for children from six large nationally representative cross sectional surveys on growth from Brazil, Great Britain, Hong Kong, the Netherlands, Singapore, and the United States. Each survey had over 10 000 subjects, with ages ranging from 6-18 years.

Centile curves
Centile curves for body mass index were constructed for each dataset by sex using the LMS method.¹³ The fitted LMS curves allow an extra centile curve to be drawn for each dataset, passing through the adult cut off point for obesity of 30 kg/m² at age 18. Superimposing the curves of the six datasets leads to a cluster of centile curves that all pass through the adult cut off point yet represent a wide range of obesity. The hypothesis is that the relation between cut off point and prevalence at different ages gives the same curve shape irrespective of country or obesity. If sufficiently similar the curves can be averaged to provide a single smooth curve passing through the adult cut off point. The curve is representative of all the datasets involved but is unrelated to their obesitythe cut off point is effectively independent of the spectrum of obesity in the reference data. A curve for overweight passing through 25 kg/m² at age 18 is obtained in the same way.

	Results

Top Abstract Introduction Subjects and methods Results Discussion References

Table 1 gives the centiles for overweight and obesity corresponding to a body mass index of 25 and 30 kg/m² at age 18 for each dataset by sex. The prevalence range at 18 years is 4.7-18.1% for overweight and 0.1-4.0% for obesity.

View this table: [in this window] [in a new window]   Table 1. Centiles and z scores for overweight and obesity corresponding to body mass index of 25 kg/m2 and 30 kg/m2 at age 18 years in six datasets, derived from fitted LMS curves

Figure 1 presents the centile curves for overweight for the six datasets by sex, passing through the adult cut off point of 25 kg/m² at age 18. Figure 2 gives the corresponding centile curves for obesity in each dataset, passing through a body mass index of 30 kg/m² at age 18. The curves are reasonably consistent across countries between ages 8 and 18, although those for Singapore are higher between ages 10 and 15. This is due partly to an increased median and partly to greater variability.

View larger version (22K): [in this window] [in a new window]   Fig 1.   Centiles for overweight by sex for each dataset, passing through body mass index of 25 kg/m2 at age 18

View larger version (24K): [in this window] [in a new window]   Fig 2.   Centiles for obesity by sex for each dataset, passing through body mass index of 30 kg/m2 at age 18

Table 2 and figure 3 show international cut off points for body mass index for overweight and obesity from 2-18 years, obtained by averaging the centile curves in figures 1 and 2. From 2-6 years the cut off points do not include Singapore because its data start at age 6 years.

	Discussion

Top Abstract Introduction Subjects and methods Results Discussion References

Our method addresses the two main problems of defining internationally acceptable cut off points for body mass index for overweight and obesity in children. ^{11 12} The reference population was obtained by averaging across a heterogeneous mix of surveys from different countries, with widely differing prevalence rates for obesity, whereas the appropriate cut off point was defined in body mass index units in young adulthood and extrapolated to childhood, conserving the corresponding centile in each dataset.

Although less arbitrary and potentially more internationally acceptable than other cut off points, this approach still provides a statistical definition, with all the implied advantages and disadvantages.¹⁴ Our terminology corresponds to adult cut off points, but the health consequences for children above the cut off points may differ from those for adults. Nonetheless, the cut off points based on a heterogeneous worldwide population can be applied widely to determine whether the children and adolescents they identify are at increased risk of morbidity related to obesity.

Agreement of the centile curves
The major uncertainty with our approach, and the test of its validity, is the extent to which the centile curves for the datasets are of the same shape. Figures 1 and 2 show that although the agreement is reasonable it is not perfect.

Nothing obvious explains Singapore's unusual pattern of overweight in puberty. Omitting it from the averaged country curves would lower the cut off points for both sexes by less than 0.4 body mass index units at age 11-12. Therefore, even though Singapore looks different from the other countries, its impact on the cut off points is only modest. Because there is no a priori reason to exclude Singapore, and because so little is known about growth patterns across countries, we have chosen to retain it in the reference population.

Extending the dataset
We recognise that the reference population made up of these countries is less than ideal. It probably reflects Western populations adequately but lacks representation from other parts of the world. The Hong Kong sample may, however, be fairly representative of the Chinese, and the Brazilian and US datasets include many subjects of African descent. Although additional datasets from Africa and Asia would be helpful, our stringent inclusion criteria of a large sample, national representativeness, minimum age range 6-18 years, and data quality control, mean that further datasets are unlikely to emerge from these continents in the foreseeable future. To our knowledge no other available surveys satisfy the criteria. It is not realistic to wait for them because there is an urgent need for international cut off points now. Also, our methodology aims to adjust for differences in overweight between countries, so it could be argued that adding other countries to the reference set would make little difference to the cut off points. None the less, further research is needed to explore patterns of body mass index in children in Africa and Asia.

View this table: [in this window] [in a new window]   Table 2. International cut off points for body mass index for overweight and obesity by sex between 2 and 18 years, defined to pass through body mass index of 25 and 30 kg/m2 at age 18, obtained by averaging data from Brazil, Great Britain, Hong Kong, Netherlands, Singapore, and United States

View larger version (16K): [in this window] [in a new window]   Fig 3.   International cut off points for body mass index by sex for overweight and obesity, passing through body mass index 25 and 30 kg/m2 at age 18 (data from Brazil, Britain, Hong Kong, Netherlands, Singapore, and United States)

Puberty
The body mass index curves in figure 3 show a fairly linear pattern for males but a higher and more concave shape for females. This sex difference can also be seen in the individual curves of figures 1 and 2 reflecting earlier puberty in females. The sensitivity of the curve's shape to the timing of puberty may affect the performance of the cut off points in countries where puberty is appreciably delayed,¹⁵ although delays of less than two years are unlikely to make much difference.

Conclusions
Our analysis provides cut off points for body mass index in childhood that are based on international data and linked to the widely accepted adult cut off points of a body mass index of 25 and 30 kg/m². Our approach avoids some of the usual arbitrariness of choosing the reference data and cut off point. Applying the cut off points to the national datasets on which they are based gives a wide range of prevalence estimates at age 18 of 5-18% for overweight and 0.1-4% for obesity. A similar range of estimates is likely to be seen from age 2-18. The cut off points are recommended for use in international comparisons of prevalence of overweight and obesity.

What is already known on this topic Child obesity is a serious public health problem that is surprisingly difficult to define The 95th centile of the US body mass index reference has recently been proposed as a cut off point for child obesity, but like previous definitions it is far from universally accepted What this study adds A new definition of overweight and obesity in childhood, based on pooled international data for body mass index and linked to the widely used adult obesity cut off point of 30 kg/m2, has been proposed The definition is less arbitrary and more international than others, and should encourage direct comparison of trends in child obesity worldwide

	Acknowledgments

We thank Carlos Monteiro (Brazil), Sophie Leung (Hong Kong), Machteld Roede (the Netherlands), and Uma Rajan (Singapore), for allowing us access to their data.

Contributors: TJC had the original idea, did most of the statistical analyses, and wrote the first draft of the paper. TJC, MCB, KMF, and WHD provided the data. KMF did further analyses of the US data. All authors attended the original childhood obesity workshop, participated in the design and planning of the study, discussed the interpretation of the results, and contributed to the final paper. TJC will act as guarantor for the paper.

	Footnotes

Funding: This work was supported by the Childhood Obesity Working Group of the International Obesity Task Force. TJC is supported by a Medical Research Council programme grant.

Competing interests: None declared.

A longer version of this paper can be found on the BMJ's website

	References

Top Abstract Introduction Subjects and methods Results Discussion References

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4.	Mahoney LT, Burns TL, Stanford W. Coronary risk factors measured in childhood and young adult life are associated with coronary artery calcification in young adults: the Muscatine study. J Am Coll Cardiol 1996; 27: 277-284[Medline].
5.	Malina RM, Katzmarzyk PT. Validity of the body mass index as an indicator of the risk and presence of overweight in adolescents. Am J Clin Nutr 1999; 70: 131-16S.
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7.	Rolland-Cachera MF, Sempé M, Guilloud-Bataille M, Patois E, Pequignot-Guggenbuhl F, Fautrad V. Adiposity indices in children. Am J Clin Nutr 1982; 36: 178-184[Abstract].
8.	Cole TJ, Freeman JV, Preece MA. Body mass index reference curves for the UK, 1990. Arch Dis Child 1995; 73: 25-29[Abstract].
9.	Power C, Lake JK, Cole TJ. Measurement and long-term health risks of child and adolescent fatness. Int J Obesity 1997; 21: 507-526.
10.	Barlow SE, Dietz WH. Obesity evaluation and treatment: expert committee recommendations. The Maternal and Child Health Bureau, Health Resources and Services Administration, and the Department of Health and Human Services. Pediatrics 1998; 102: E29[Abstract/Full Text].
11.	Dietz WH, Robinson TN. Use of the body mass index (BMI) as a measure of overweight in children and adolescents. J Pediatr 1998; 132: 191-193[Medline].
12.	Bellizzi MC, Dietz WH. Workshop on childhood obesity: summary of the discussion. Am J Clin Nutr 1999; 70: 173-15S[Abstract/Full Text].
13.	Cole TJ, Freeman JV, Preece MA. British 1990 growth reference centiles for weight, height, body mass index and head circumference fitted by maximum penalized likelihood. Stat Med 1998; 17: 407-429[Medline].
14.	Flegal KM. Defining obesity in children and adolescents: epidemiologic approaches. Crit Rev Food Sci Nutr 1993; 33: 307-312[Medline].
15.	D'Amato M, Ferro-Luzzi A, Gundry S, Wright J, Worrall J, Mucavele P. A new approach to assessing adolescent malnutrition in low income countries. A case study in Zimbabwe. Abstract presented at the International Biometric Society, Italian region. Rome, 7-9 Jul 1999.

(Accepted 21 January 2000)

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Rapid Responses:

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