The use of anthropometry in the prevention of childhood overweight and obesity.
ABSTRACT To review concepts and propose measures related to the use of anthropometry for early identification of excessive weight gain in children.
Review of results from national and international studies focusing on the assessment of childhood growth, and evaluation of the weight-for-height z-scores of individual children using the 1977 National Center for Health Statistics and the 2000 Centers for Disease Control and Prevention growth charts.
At present, few countries (23%) use indicators based on weight and height measurements to classify child body weight status. Less than one-third of growth monitoring programmes assess the growth of children beyond 6 y of age. Growth charts based on descriptive samples of populations undergoing increasing trends of childhood overweight and obesity result in substantial underestimation of true rates of these conditions.
Early recognition of excessive weight gain relative to linear growth should become standard clinical practice by the following: (a) the routine collection of height measurements to enable monitoring weight-for-height and body mass index (BMI); (b) the expansion of existing monitoring programmes to include the assessment of all children up to 18 y at least once a year; (c) the interpretation of weight-for-height and BMI indices based on prescriptive reference data; and (d) the early intervention after an increase in weight-for-height or BMI percentiles has been observed.
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ABSTRACT: National survey data show increases in mean body mass index (BMI) and in the prevalence of overweight and obesity for adults and children in the United States, indicating a change in the distribution of BMI. To apply graphical methods to describe changes in the distribution of BMI. BMI values from the third National Health and Nutrition Examination Survey (NHANES III: 1988-94) were compared with data from earlier cross-sectional nationally representative surveys for adults 20-74 y of age and for children and adolescents 6-17 y of age. Tukey mean-difference plots were used to investigate the changes in the distributions of BMI within sex-age groups. Mean-difference plots allow qualitative visual comparisons of the distributions of BMI between surveys. For all sex-age groups, there was increasing skewness with a greater shift in the upper part of the distribution so that, within each group, the heaviest subgroup was heavier in NHANES III than in prior surveys. For the youngest children, the lower part of the distribution showed virtually no change. With increasing age the whole distribution tended to shift upward slightly, suggesting an increase in BMI across the entire population. These changes in the distribution of BMI suggest the combination of both profound environmental determinants and a population with a high degree of susceptibility. The reasons for the increasing prevalence of obesity should be sought in part by seeking to understand the factors causing increases in the population as a whole.International Journal of Obesity 08/2000; 24(7):807-18. · 5.22 Impact Factor
- BMJ. 01/2000; 320:1240-1243.
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ABSTRACT: The obesity epidemic shows no signs of abating. There is an urgent need to push back against the environmental forces that are producing gradual weight gain in the population. Using data from national surveys, we estimate that affecting energy balance by 100 kilocalories per day (by a combination of reductions in energy intake and increases in physical activity) could prevent weight gain in most of the population. This can be achieved by small changes in behavior, such as 15 minutes per day of walking or eating a few less bites at each meal. Having a specific behavioral target for the prevention of weight gain may be key to arresting the obesity epidemic.Science 03/2003; 299(5608):853-5. · 31.20 Impact Factor
SCN News #29
The use of anthropometry in the prevention of childhood The use of anthropometry in the prevention of childhood
overweight and obesityoverweight and obesitya a
Mercedes de Onis Mercedes de Onis
World Health Organization World Health Organization
During the past two decades the prevalence of overweight and obesity in children has increased world-
wide. Historically, a fat child meant a healthy child, and the concept of “bigger is better” was widely
accepted by paediatricians and caretakers. In recent years, however, this perception has drastically
changed as we have learnt that obesity in childhood causes a wide range of serious complications and
increases the risk of premature illness and death later in life.1,2 In view of its rapid development in ge-
netically stable populations, there is general agreement among experts that the environment, rather
than biology, is driving this epidemic.3 The lack of sign that the rapid increase in childhood obesity
seen over the past two decades is abating is raising public-health concerns. Fundamental changes in the
social environment and family life-styles will be needed to combat this emerging public-health crisis.
Although solutions to reverse the adverse environmental factors exist, they are politically difficult to
implement. The purpose of this paper is to review concepts and propose measures related to the use of
anthropometry for early identification of excessive weight gain.
Global epidemic of childhood overweight
The definitions of overweight and obesity in children often differ across studies, making comparisons
of cross-sectional prevalence data difficult. Nevertheless, several studies have documented important
increases in prevalence over time within populations in developed countries.4-8 Similarly, a recent
global analysis showed a rising trend in childhood overweight in 16 out of 38 developing countries
with more than one national survey.9 Figure 1 (next page) presents trends in selected developing coun-
tries over the past decade based on national surveys included in the WHO Global Database on Child
Growth and Malnutrition (accessed March, 2004).10 The comparison of both ends of the weight-for-
height distribution suggest a population-wide shift, with overweight replacing wasting as countries un-
dergo the nutrition transition.9 Moreover, the distribution of body mass index (BMI) has shifted in a
skewed fashion, such that the heaviest children have become even heavier.11 In view of the adverse
health consequences1,2 and the economic burden 12 of obesity in childhood and adolescence, greater
efforts to identify individuals and populations at risk are needed.
Potential measures for early identification of excessive weight gain
MONITOR THE APPROPRIATE ANTHROPOMETRIC INDICATOR
Assessing child overweight and obesity is not as straightforward as it may seem, but there is now con-
sensus that indicators based on weight and height measurements such as weight-for-height or BMI (ie,
weight (kg)/height (m)2), should be used for clinical practice and epidemiological studies to classify
child body weight status.13,14 Nevertheless, a recent global survey on child growth monitoring prac-
tices15 showed that weight-for-age was the anthropometric indicator universally used (97% of coun-
tries), while only 23% of the countries used weight-for-height, with BMI being rarely used. The results
from this study indicate that at present only a few countries have in place growth monitoring systems
that allow early identification of children at risk of becoming overweight and/or obese. National pro-
grammes need to include the routine collection of height measurements (recumbent length up to two
years of age and standing height for older children) to allow the monitoring of weight-for-height and/
or BMI for the early identification of children at risk of overweight and obesity.
MONITOR THE GROWTH OF ALL CHILDREN UP TO 18 YEARS OF AGE
The same study demonstrated that less than one third of countries expand growth monitoring activities
beyond 6 years of age. Figure 2 (page 29) presents the age coverage of the growth charts collected
from 154 countries.15 The majority (55%) of charts were used for infants and young children (0-5
years), 29% covered birth to adolescence (0-18 years), while the rest were applied to variable age spans
a Reprinted by permission from the International Journal on Obesity (de Onis M. The use of anthropometry in the
prevention of childhood overweight and obesity. 2004; 28:S81-85), copyright (2004) Macmillan Publishers Ltd.
SCN News #29
or unspecified ranges. The main reason for greater programme focus on preschool versus older chil-
dren is the absence of agreed criteria and appropriate reference data to monitor growth in school-age
children and adolescents. However, the need for an expansion of the age range to cover older children
and adolescents in monitoring efforts is evident. National programmes aimed at the prevention of
overweight and obesity should include the assessment of all children up to 18 years of age at least once
USE OF PRESCRIPTIVE REFERENCE DATA TO INTERPRET GROWTH MEASUREMENTS
Child growth measurements are compared across individuals or populations in relation to a set of ref-
erence values. Because in practice the use of reference values embraces the notion of a norm or desir-
able target, the interpretation of weight-for-height indices to classify individuals and populations as
normal, overweight or obese, is highly dependent on the reference data used.16 The American Acad-
emy of Pediatrics in a recent policy statement recommended the use of the newly developed Centers
for Disease Control and Prevention (CDC) 2000 growth charts for the assessment and monitoring of
child overweight and obesity.14 These charts were created to update the 1977 National Center for
Health Statistics (NCHS) charts using data, for most part, from five cross-sectional child growth sur-
veys involving nationally representative samples.17 One purpose of the growth charts is to provide cut-
offs to define overweight and obesity, and the prevalence of both of these conditions is linked to the
cut-offs chosen. For example, the 85th centile identifies 15% of the reference population as overweight.
If growth charts are updated using representative samples of populations undergoing increasing trends
of overweight and obesity, the resulting descriptive references will be more skewed to the right and will
underestimate the true rates of overweight and obesity. Such a situation applies to the CDC 2000
growth charts. Figure 3 (page 30) presents the mean weight-for-age z-score of a sample of healthy
breastfed infants relative to the 1977 NCHS and the CDC 2000 references.18 As shown in the figure,
the pattern of growth of the breastfed sample is remarkably similar when assessed against the two ref-
erences, but the mean z-score plot based on the CDC 2000 reference is shifted downwards reflecting a
heavier reference sample, on average, than the 1977 NCHS sample.
The impact the upward skewness of the CDC 2000 reference has in the assessment of individual chil-
dren’s growth is shown in Table 1 (page 31). In all cases the new CDC 2000 reference substantially
underestimated the weight-for-height z-scores of individual children compared to the 1977 NCHS ref-
erence. For example, a child classified close to +3 SD using the 1977 NCHS reference will be just be-
low +2 SD when the CDC 2000 reference is applied. Similarly, a child with a z-score of +10.7 based
on the 1977 NCHS reference will be below +4 SD when using the CDC 2000 reference. Because of
the implications this has for the accurate assessment and monitoring of childhood overweight and obe-
sity, the UK has recently taken the policy decision to “freeze” the British 1990 BMI reference.19,20
1 Overweight being defined as weight-for-height above 2 SDs of the National Center for Health Statistics/World
Health Organization reference median value
Trends of child overweight in selected developing countries
SCN News #29
Reference data are a fundamental tool for the interpretation of anthropometric data. Updating them
using descriptive samples of populations that are undergoing increasing trends of overweight and obe-
sity has the effect of redefining these conditions as “normal”. The recent cut off points proposed by
the International Obesity Task Force (IOTF) to classify children as overweight or obese21 seem to suf-
fer from the same biological drawback and a number of reports have shown that these cut-offs sub-
stantially underestimate the prevalence of childhood obesity in different populations.22-24 Compared to
the 1977 NCHS reference, using a sample of 1678 Russian children aged 6-9 years, the IOTF cut-offs
yielded a prevalence of obesity of about half that estimated using the NCHS reference (11.1% vs
Those responsible for updating national growth references should adopt an approach that is analogous
to the “prescriptive” approach adopted by WHO in the development of the international growth refer-
ence for infants and young children.26 The WHO Multicentre Growth Reference Study (MGRS) was
designed to provide data that describe how children should grow rather than merely describing their
growth in a particular time and place. This effort required an expanded definition of “health” that goes
beyond the absence of overt disease to the adoption of specific health behaviours by children and
families recruited into the study (eg, breastfeeding norms, standard paediatric care, and non-smoking
requirements). By adopting a prescriptive approach, the MGRS’ design explicitly recognized the need
for standards (ie, devices that enable value judgments by incorporating norms or targets in their con-
struction). Arguably, the current obesity epidemic in many developed countries might have been de-
tectable earlier if a prescriptive reference had been available 20 years ago. The main drawback of the
forthcoming WHO/MGRS growth curves is that they will cover children only up to 5 years of age.
The need to expand this effort to older children is evident.
PREVENTION AND EARLY INTERVENTION
Early recognition of excessive weight gain relative to linear growth is essential throughout childhood.
Changes on growth patterns, such as upward crossing of weight-for-height or BMI percentiles, should
be recognized using the appropriate reference data and addressed before children are severely over-
weight. Underlying predisposing factors should be discussed with parents and other caregivers and
dietary and physical activity interventions initiated straight away after an increase in weight-for-height
or BMI percentiles has been observed. Although data are extremely limited, it is likely that intervention
before overweight has become severe will be more successful. The pediatric community should take a
leadership role in the prevention and early recognition of childhood overweight and obesity by incor-
porating into routine clinical practice assessment and anticipatory guidance about weight, diet and
The recent increases in child overweight and obesity are largely attributed to social and environmental
forces which are not under the individual control of children and which, in turn, influence eating and
physical activity behaviours.3,27 Many countries have experienced in the past 20 years important social
changes that have affected family eating patterns and the consumption of fast foods, pre-prepared
meals, and soft drinks. Likewise, the amount of physical activity that children engage in has been re-
Age groups covered by national growth charts
SCN News #29
duced by an increase use of cars, an increase in the amount of time spent watching television (with
multiple TV channels around the clock) and playing sedentary games, and a decrease in the opportuni-
ties for physical activity on the way to school, at school, or during leisure time. Thus, although inter-
ventions to improve individual lifestyles are needed, especially for children already overweight or
obese, remedial actions taken from a broader public health and policy perspective will be necessary to
have a significant impact on the problem.
The treatment of obesity ultimately involves eating less and being more physically active. As simple as
this may sound, long-term weight loss has proven difficult to achieve and, overall, there has been a lack
of success of treating obesity once it has become established.27,28 The psychological immaturity of chil-
dren and their greater susceptibility to peer pressure compared to adults, present additional difficulties
to the successful treatment of childhood obesity. Because of this, there seems to be consensus that
prevention is the most realistic and cost effective approach for dealing with the problem of childhood
The development of timely and effective preventive strategies requires that health practitioners, par-
ticularly paediatricians, successfully identify individuals and populations at risk. Early recognition of
excessive weight gain relative to linear growth should become standard clinical practice by the:
1. Routine collection of height measurements (recumbent length up to 2 years of age and standing
height for older children) to enable monitoring weight-for-height and BMI. These indices
should be calculated and plotted periodically.
2. Expansion of existing programmes to include the assessment of all children up to 18 years at
least once a year.
3. Interpretation of weight-for-height and BMI indices based on prescriptive reference data. Such
data will soon be available for preschool age children. There is a need to expand this effort to
school age children and adolescents. Until then, countries should freeze their national references
and avoid updating them based on recent, heavier, descriptive samples.
4. Early intervention after an increase in weight-for-height or BMI percentiles has been observed
to provide parents and caregivers guidance and support to promote healthy eating habits and
routine physical activity.
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Science, 2003, 299:853-855.
4. Troiano RP, Flegal KM, Kuczmarski RJ, Campbell SM, Johnson CL. Overweight prevalence and
trends for children and adolescents. The National Health and Nutrition Examination Surveys, 1963 to
Mean weight-for-age z-scores of breastfed infants relative to the 1977 Na-
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ease Control and Prevention (CDC) references
Source: de Onis M and Onyango A, 2003 (18)
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Malnutrition: methodology and applications. International Journal of Epidemiology, 2003, 32:518-526.
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No. 854. Geneva: World Health Organization, 1995.
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16. de Onis M, Habicht JP. Anthropometric reference data for international use: recommendations
from a World Health Organization Expert Committee. American Journal of Clinical Nutrition, 1996,
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Williams AF. Growth reference charts for use in the United Kingdom. Archives of Disease in Childhood,
Effect of increased upward skewness of CDC 2000 growth reference compared to the
1977 NCHS reference on weight-for-height z-scores.
+3.65 Boy 25.3 103.0
Girl 48 35.1 103.7 +10.70 +3.58
Girl 74 47.8 121.2 +9.42 +3.27
Girl 78 29.4 120.1 +2.91 +1.97
Girl 52 32.3 109.4 +7.36 +2.96
Boy 22 16.8 91.3 +3.29 +2.74
Boy 43 24.3 105.4 +4.34 +2.97
Girl 62 32.9 111.4 +7.05 +2.87
Boy 58 45.2 119.0 +9.96 +2.72
Boy 42 26.4 112.5 +3.64 +2.30
1 Weight-for-height standard deviations