Asimpleguidetoclassifying

bodymassindexinchildren
June 2011

DeliveredbyNOOonbehalfofthePublicHealthObservatoriesinEngland
NOO|Asimpleguidetoclassifyingbodymassindexinchildren

Whatisthepurposeofthispaper?

Thispaperprovidesasimpleguidetohowbodymassindex(BMI)canbeusedtoassessthe
weightstatusofchildren.Itdescribesthedifferentmethodsthatcanbeusedtointerpret
BMIinchildrenandyoungpeople,explainshowthemethodsdifferandwhereeachmethod
iscommonlyused.

WhydoweuseBMI?

BMI provides a good indicator for levels of body fat, and it is known that having a
BMIthatiseithertoolowortoohighisassociatedwithanincreasedriskofillhealth
duringchildhoodaswellaslaterinlife.
BMI is relatively quick and easy to calculate and as a result, is used for population
surveysandbyhealthprofessionalswhenassessingindividualpatients.
BMIisthereforethemostfrequentlyusedmeasureforassessingwhetheradultsor
childrenareobese,overweight,underweight,orahealthyweight.

WhyisBMIclassificationdifferentforchildrenandadults?

TheBMIofadultsremainsrelativelyconstantunlesstheygainorlosealotofweight.
WhenclassifyingtheBMIofadultsitisthereforepossibletousethesamecategories
(alsocalledthresholds,orcutoffs)fordefiningunderweight,overweightorobesity,
regardlessoftheageandsexoftheadult.
Adults (aged 18 years and above) of all ages are usually classified as obese if their
BMIexceeds30kg/m,oroverweightiftheirBMIisgreaterthan25kg/m.Individuals
withaBMIoflessthan18.5kg/mareusuallyconsideredunderweight.
AssessingtheBMIofchildrenismorecomplicatedthanforadultsbecauseachilds
BMIchangesastheymature.Also,thesepatternsofgrowthdifferbetweenboysand
girls.Therefore,toworkoutwhetherachildsBMIistoohighortoolow,boththe
ageandsexofthechildneedtobetakenintoaccount.
Because childrens BMI changes considerably between birth and adulthood, fixed
thresholds such as those used for adults should not be applied to children as they
wouldprovidemisleadingfindings.

HowischildBMIclassified?

InsteadofusingfixedBMIvaluestoclassifyindividuals(asusedforadults)childrens
BMIisclassifiedusingthresholdsthatvarytotakeintoaccountthechildsageand
sex.
Thesethresholdsareusuallyderivedfromareferencepopulation,knownasachild
growthreference.Theyarecalculatedbyweighingandmeasuringalargesampleof
childrenandtheyillustratehowBMIvariesinchildrenofdifferentagesandsex.As
wellasshowingthepatternofgrowth,thesedataalsoprovideanaverageBMIfora
boy or girl at a particular age, and the distribution of measurements above and
below this value. This means that individual children can be compared to the
reference population and the degree of variation from the expected value can be
calculated.

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BMIthresholdsarefrequentlydefinedintermsofaspecificzscore,orcentile,ona
childgrowthreference.OnceachildsBMIcentileorzscorehasbeencalculated,this
figure can then be checked to see whether it is above or below the defined
thresholdsforthechildgrowthreferenceused.
Thereareanumberofdifferentchildgrowthreferencesavailable.Thelastsectionof
thispaperdescribesthesedifferentreferences,andalsodescribeswhenandwhere
theyarecommonlyused.
Each growth reference tends to have a set of recommended thresholds. These
thresholds are usually defined by statistical conventions, for example, a whole
numberofstandarddeviationsfromthemean,orawholenumberofcentiles(such
asthe85thand95thcentiles).OneexceptionistheInternationalObesityTaskForce
(IOTF) thresholds which are derived to line up with the adult BMI thresholds for
obesityandoverweightatage18years.

Whatarethedifferentchildgrowthreferences?

Many countries have their own populationspecific thresholds for assessing BMI in
children. The child growth references that are commonly used in UK and
internationalstudiesaresummarisedbelow.
InEnglandtheBritish1990growthreference(UK90)isrecommendedforpopulation
monitoringandclinicalassessmentinchildrenagedfouryearsandover.OtherBMI
thresholdsaresometimesused,particularlyforinternationalcomparisonofobesity
prevalence.
Itmustbenotedthatdatashouldonlybecomparedwhenthesamethresholdhas
beenapplied.Forexample,comparisonsshouldnotbemadeofobesityprevalence
usingtheUK90growthreferencewithobesityprevalencecalculatedusingtheIOTF
thresholds.
The UK90, IOTF, Centers for Disease Control (CDC) charts and World Health
Organization (WHO) charts for ages from 5 to 19 are growth references which
providecomparatorswiththegeneralpopulation,whereastheWHOchartsforages
0upto5areagrowthstandardandaimtoprovideanindicatorofoptimalgrowth.

WhatchildBMIreferencesareusedintheUKandininternationalstudies?

Thefollowingpagesprovideaquestionandanswersummaryofthemostcommonlyused
child BMI thresholds in the UK. For each set of thresholds the reference population is
described, and a brief summary given of the methodology and cutoffs used for defining
underweight,overweight,andobesityinchildren.

Examples are given of the main uses of each set of thresholds within the UK and
internationally.Linkstofurtherinformationareprovidedtowebsitesandacademicpapers.

ABMIzscoreorstandarddeviationscoreindicateshowmanyunits(ofthestandarddeviation)achildsBMI
isaboveorbelowtheaverageBMIvaluefortheiragegroupandsex.Forinstance,azscoreof1.5indicates
thatachildis1.5standarddeviationsabovetheaveragevalue,andazscoreof1.5indicatesachildis1.5
standarddeviationsbelowtheaveragevalue.

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British1990growthreference(UK90)

1. Whatisthesizeofthereferencepopulationandwhenwerethedatacollected?
The UK90 BMI reference provides centile curves for BMI for British children from
birth to 23 years. They are based on a sample of 32,222 measurements from 12
distinct surveys collected between 1978 and 1994. The BMI reference curves are
partofthewiderBritish1990growthreferencewhichalsoincludesheight,weight,
headcircumferenceandwaistcircumference.

2. Whatagerangeofchildren/youngpeoplearecovered?
023years.

3. Whatgeographicareaswerethereferencepopulationsampledfrom?
UKpopulationonly.

4. WhatBMIcutoffsareused?
Underweight:2ndcentileforpopulationmonitoringandclinicalassessment
Overweight: 85th centile for population monitoring, 91st centile for clinical
assessment
Obese:95thcentileforpopulationmonitoring,98thcentileforclinicalassessment.

TheUK90BMIreferenceisavailableonprintedgrowthcharts,wherethecentilesare
shownevenlyspacedat2/3rdsofastandarddeviation.Thismeansthe0.4th,2nd,
9th,25th,50th,75th,91st,98thand99.6thcentilesareshown.

5. Howarethesethresholdscurrentlyused?
Forchildrenagedfouryearsandover:
Population monitoring thresholds are used for most published obesity and
overweight prevalence figures, e.g. those using Health Survey for England and
NationalChildMeasurementProgramme(NCMP)data;
Clinical cutoffs are recommended by NICE for use in clinical settings with
individualchildren.AlsousedforNCMPparentalfeedbackandtheNHSchoices
BMIcalculator.

TheUK90thresholdsarerarelyusedoutsideofUK.

6. WherecanIgoforfurtherinformation?
Chartsavailabletoorderat:www.healthforallchildren.co.uk
PublishedintheADC:http://adc.bmj.com/content/73/1/25
ColeTJ,FreemanJV,PreeceMA.BodymassindexreferencecurvesfortheUK,
1990.ArchivesofDiseaseinChildhood1995;73:259.
Cole TJ, Freeman JV, Preece MA. British 1990 growth reference centiles for
weight, height, body mass index and head circumference fitted by maximum
penalizedlikelihood.StatisticsinMedicine1998;17:40729.
FreemanJV,ColeTJ,ChinnS,JonesPRM,WhiteEM,PreeceMA.Crosssectional
stature and weight reference curves for the UK, 1990. Archives of Disease in
Childhood1995;73:1724.

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InternationalObesityTaskForce(IOTF)cutoffs

1. Whatisthesizeofthereferencepopulationandwhenwerethedatacollected?
In total these samples include 192,727 children aged 0 to 25 years. Each national
datasethasover10,000subjects,withagerangescoveringatleasttheperiodfrom
6 to 18 years. The most recently available survey data from the United States
(198894) were excluded as data which predated the recent rise in obesity
prevalencewerepreferred.

2. Whatagerangeofchildren/youngpeoplearecovered?
218years.

3. Whatgeographicareaswerethereferencepopulationsampledfrom?
TheIOTFthresholdsarederivedfrombodymassindexdatafromsixlarge,nationally
representative, crosssectional surveys from Brazil, Great Britain, Hong Kong, the
Netherlands,Singapore,andtheUnitedStates.

4. WhatBMIcutoffsareused?
AgeandsexspecificcutoffpointsthatareextrapolatedfromtheadultBMIcutoffs
of 25kg/m2 and 30kg/m2 for overweight and obesity respectively. Three grades of
thinnessaredefinedfromequivalentadultBMIsof16,17and18.5.

5. Howarethesethresholdscurrentlyused?
The IOTF thresholds are widely used internationally. They are used primarily for
makinginternationalcomparisonsorwhenpresentingchildoverweightandobesity
data in academic journals. These thresholds are occasionally used with other data
sources;e.g.datafromtheMillenniumCohortStudy.

6. WherecanIgoforfurtherinformation?
Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a standard definition for
child overweight and obesity worldwide: international survey. BMJ 2000;320:
12403.
Cole TJ, Flegal KM, Nicholls D, Jackson AA. Body mass index cutoffs to define
thinness in children and adolescents: international survey. BMJ 2007;335: 194
202.

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WorldHealthOrganization(WHO)ChildGrowthStandard

1. Whatisthesizeofthereferencepopulationandwhenwerethedatacollected?
TheBMIstandardisbasedonatotalof26,985recordswithbothweightandlength
(024 months) or height (2471 months), information taken from the Multicentre
GrowthReferenceStudy(MGRS)between1997and2003.Thisstudyalsoincludeda
longitudinal followup from birth to 24 months and a crosssectional survey of
childrenaged18to71months.

Standardsareprovidedbysexand:length/heightforage;weightforage;weightfor
length;weightforheightaswellasBMIforage.

2. Whatagerangeofchildren/youngpeoplearecovered?
05years.

3. Whatgeographicareaswerethereferencepopulationsampledfrom?
The WHO Child Growth Standard is based on an international sample from Brazil,
Ghana,India,Norway,OmanandtheUnitedStates.

4. WhatBMIcutoffsareused?
WHOsuggestasetofthresholdsbasedonsinglestandarddeviationspacing(i.e.+1
SD,+2SDetc).

HoweverontheWHO/UK90childgrowthcharts(forusewithchildrenagedunder
fouryears),the91stand98thcentilesareshownforclassifyingindividualchildrenas
overweightorobese.Forpopulationmonitoringinthisagegroupthe85thand95th
centilesoftheWHOreferenceareused.

5. Howarethesethresholdscurrentlyused?
The WHO Child Growth Standard is used internationally, although IOTF is more
widelyused.

GrowthStandardsfor04yearsarerecommendedforuseintheUK.

6. WherecanIgoforfurtherinformation?
www.who.int/childgrowth/standards/
http://www.bmj.com/content/340/bmj.c1140

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WorldHealthOrganization(WHO)2007growthreference

1. Whatisthesizeofthereferencepopulation,andwhenwerethedatacollected?
TheWHO2007growthreferencewasdevelopedusingthesamemethodasusedfor
theWHOGrowthStandards,butmergingdatafromthecrosssectionalcomponent
of the WHO Multicentre Growth Reference Study (MGRS) (for children aged 1871
months) with data used for the earlier National Center for Health Statistics
(NCHS)/WHOgrowthreference(childrenaged124years).

TheNCHS/WHOreferencewasbasedonasampleofchildrenfromtheUnitedStates
ofEuropeanancestry,collectedduringthe60sand70s.

The2007referenceisavailableforbothheightandweightforageaswellasforBMI.
The WHO 2007 reference almost perfectly aligns with the WHO Child Growth
Standardsatagefiveyears.

2. Whatagerangeofchildren/youngpeoplearecovered?
519years.

3. Whatgeographicareaswerethereferencepopulationsampledfrom?
The WHO 2007 growth reference was derived from a combination of the USA
NationalCentreforHealthStatistics1977pooledgrowthdata,andtheWHOMulti
centre Growth Reference Study (MGRS) from Brazil, Ghana, Norway, India, Oman,
USA.

4. WhatBMIcutoffsareused?
WHOsuggestasetofthresholdsbasedonsinglestandarddeviationspacing.
Thinness:<2SD
Overweight:between+1SDand<+2SD
Obese:>+2SD

5. Howarethesethresholdscurrentlyused?
The WHO 2007 growth reference is used internationally, although the IOTF
thresholdsaremorewidelyused.

6. WherecanIgoforfurtherinformation?
www.who.int/growthref/en/
WHOMulticentreGrowthReferenceStudyGroup.WHOChildGrowthStandards
ActaPaediatricaSupplement2006;450
deOnisM,OnyangoAW,BorghiE,SiyamA,NishidaC,SiekmannJ.Development
ofaWHOgrowthreferenceforschoolagedchildrenandadolescents.Bulletinof
theWorldHealthOrganization,2007;85(9):649732.
Must A, Dallal GE, Dietz WH. Reference data for obesity: 85th and 95th
percentilesofbodymassindex(wt/ht)andtricepsskinfoldthickness.American
JournalofClinicalNutrition1991;53:83946.

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UnitedStatesCentersforDiseaseControlandprevention(CDC)2000growthreference

1. Whatisthesizeofthereferencepopulationandwhenwerethedatacollected?
The CDC 2000 growth reference was developed using five national health
examination surveys (the National Health Examination Survey (NHES) and the
National Health and Nutrition Examination Survey (NHANES)) for girls and boys.
Somelimitedsupplementaryinformationwascollectedfromvitalstatisticsonchild
birth weight, length, and head circumference sourced from birth certificates and
hospitalrecords(19631995).

2. Whatagerangeofchildren/youngpeoplearecovered?
220years.

3. Whatgeographicareaswerethereferencepopulationsampledfrom?
USApopulationonly.

4. Whatcutoffsareused?
TheCDC2000growthreferencedefineschildrenasatriskofoverweightandobesity
if their BMI exceeds the 85th and 95th centiles for most routine assessment. The
90thand97thcentilesareusedforspecialhealthcarerequirements.Thethirdand
fifthcentilesareusedtodefineunderweightstatus.

5. Howarethesethresholdscurrentlyused?
TheCDC2000growthreferenceisprimarilyusedintheUnitedStates.

6. WherecanIgoforfurtherinformation?
www.cdc.gov/nchs/data/series/sr_11/sr11_246.pdf
www.cdc.gov/growthcharts/cdc_charts.htm

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ReaderInformation

Title

Asimpleguidetoclassifyingbodymassindexinchildren

Author(s)

HywellDinsdale
CarolineRidler
LouisaElls

Publicationdate

June2011

Targetaudience

PublicHealthObservatories
PrimaryCareTrusts
LocalAuthorities

Description

Asimpleguideonhowbodymassindex(BMI)canbeused
toassesstheweightstatusofchildren.Thispaper
describesthedifferentmethodsthatcanbeusedto
interpretBMIinchildrenandyoungpeople.

Howtocite

DinsdaleH,RidlerC,EllsLJ.Asimpleguidetoclassifyingbody
massindexinchildren.Oxford:NationalObesityObservatory,
2011.

Contact

NationalObesityObservatory
www.noo.org.uk
[email protected]

Electroniclocation

http://www.noo.org.uk/publications

Copyright

NationalObesityObservatory,2011

National Obesity Observatory

NOO|Asimpleguidetoclassifyingbodymassindexinchildren