Waist Circumference and Mid-Upper Arm Circumference in Evaluation of Obesity in Children Aged Between 6 and 17 Years-Original Article

Abstract

The purpose of this study was to determine the cut-off values for waist circumference (WC) and mid-upper arm circumference (MUAC) and to assess their use in screening for obesity in children.
Anthropometric measurements of a total of 2621 boys and 2737 girls aged 6-17 years were analyzed. WC and MUAC values were compared with ROC analysis using body mass index (BMI) cut-off values of the International Obesity Task Force (IOTF) and using WC≥ 90th percentile.for MUAC.
In both genders, except for boys and girls in the 6-year age group and post-pubertal boys, the differences between area under curve (AUC) values for WC and MUAC were not significant, indicating that both indices performed equally well in predicting obesity. Sensitivity was suboptimal through age groups 6-9 years in the boys and sensitivity was suboptimal at 6, 7,14 and 17 years both in boys and girls.
We conclude that MUAC can be a useful parameter in screening obesity and body fat distribution in children and, can be applied in epidemiological studies and in clinical practice.

Full text

J Clin Res Ped Endo 2010;2(4):144-150
DOI: 10.4274/jcrpe.v2i4.144
M. Mümtaz Maz›c›o¤lu1, Nihal Hatipo¤lu2, Ahmet Öztürk3, Betül Çiçek4, H. Bahri Üstünbafl1, Selim Kurto¤lu5
1Department of Family Medicine, School of Medicine, Erciyes University, Kayseri, Turkey
2Departman of Pediatric Endocrinology, Sisli Etfal Education and Research Hospital, Istanbul, Turkey
3Department of Biostatistics, School of Medicine, Erciyes University, Kayseri, Turkey
4Department of Nutrition and Dietetics, Atatürk Health School, Erciyes University, Kayseri, Turkey
5Department of Pediatric Endocrinology, School of Medicine, Erciyes University, Kayseri, Turkey
Address for Correspondence
Nihal Hatipoglu MD, Department of Pediatric Endocrinology, Sisli Etfal Education and Research Hospital, ‹stanbul, Turkey
Gsm: +90 536 323 03 02 Fax: +90 352 437 52 85 E-mail: nihalhatipoglu@yahoo.com
© Journal of Clinical Research in Pediatric Endocrinology, Published by Galenos Publishing.
Waist Circumference and Mid-Upper Arm
Circumference in Evaluation of Obesity in
Children Aged Between 6 and 17 Years
Original Article
144
Introduction
The global trend of increasing childhood obesity is well
documented. Obesity in childhood has therefore become a
health issue of concern to health professionals throughout the
world as a leading factor for certain chronic diseases such as
hyperlipidaemia, hyperinsulinemia, hypertension, and early
atherosclerosis (1,2,3). Whether it persists or not in adulthood,
childhood obesity is substantially related with increased
morbidity and mortality (4). However, the detection of obesity
during childhood is more difficult than during adulthood due to
the developmental changes in children. Additionally, there is no
general consensus on the reliability, use, application of direct
and indirect anthropometric indices describing obesity in
children (5).
For diagnosis of obesity and for evaluation of current and
future metabolic risks, individual assessment with body mass
index (BMI) is essential, but additional anthropometric indices
are needed to describe accurately the body fat distribution.
Although precise methods to determine body fat content
and distribution exist, these methods are not practical for
epidemiologic studies. On the other hand, anthropometric
indices provide a valid tool to screen large groups (6).
Waist circumference (WC), skinfold thickness and
mid-upper arm circumference (MUAC) are the leading indirect
methods used to assess fat reserve and the application of these
anthropometric indices is recommended to screen the child and
adolescent population for obesity (7).
ABSTRACT
Objective: The purpose of this study was to determine the cut-off values for
waist circumference (WC) and mid-upper arm circumference (MUAC) and to
assess their use in screening for obesity in children.
Methods: Anthropometric measurements of a total of 2621 boys and 2737
girls aged 6-17 years were analyzed. WC and MUAC values were compared
with ROC analysis using body mass index (BMI) cut-off values of the
International Obesity Task Force (IOTF) and using WC≥90th percentile.for
MUAC.
Results: In both genders, except for boys and girls in the 6-year age group and
post-pubertal boys, the differences between area under curve (AUC) values for
WC and MUAC were not significant, indicating that both indices performed
equally well in predicting obesity. Sensitivity was suboptimal through age
groups 6-9 years in the boys and sensitivity was suboptimal at 6, 7,14 and 17
years both in boys and girls.
Conclusions: We conclude that MUAC can be a useful parameter in
screening obesity and body fat distribution in children and, can be applied in
epidemiological studies and in clinical practice.
KKeeyy wwoorrddss::
Mid-upper arm circumference, obesity, waist circumference
CCoonnfflliicctt ooff iinntteerreesstt::None declared
RReecceeiivveedd::28.10.2010 AAcccceepptteedd::09.11.2010
This is an open-access article distributed under the terms of the Creative Commons Attiribution License, which
permits unrestricted use, distribution and reprodiction in any medium, provided the original work is properly cited.

145
Maz›c›o¤lu MM et al.
Waist and Mid-Upper Arm Circumference
Table 1. Mean (95%CI) and median (minimum-maximum) values for WC, MUAC, BMI in male and female Turkish children and adolescents
Boys Age* n MUAC (cm) WC (cm) BMI (kg/m2) Girls Age* n MUAC (cm) WC (cm) BMI (kg/m2)
(years) χ(95% CI)†χ(95% CI)†χ(95% CI)†(years) χ(95% CI)†χ(95% CI)†χ(95% CI) †
Med (min-max) ‡Med (min-max) Med (min-max) Med (min-max) ‡Med (min-max) Med (min-max)
6 124 17.1 (16.7-17.3) 53.7 (52.9-54.4) 16.6(16.3-16.9) 6 126 17.1 (16.7-17.4) 53.3 (0.4) 16.3 (0.2)
17.0 (13.9-21.0) 53.5 (46.0-65.0) 16.4 (12.6- 23.2) 17.1 (13.9-21.0) 53.0 (45.0-69.0) 16.1 (13.1-21.2)
7 208 17.4 (17.0-17.6) 54.5 (53.8-55.3) 16.8(16.6-17.1) 7 166 17.5 (17.1-17.7) 54.3 (53.5-55.0) 16.5 (16.3-16.8)
17.3 (14.0-23.7) 54.5 (41.0-71.0) 16.5 (13.0-24.3) 17.5 ()14.0-24.0) 54.0 (45.0-68.0) 16.4 (12.1-22.4)
8 196 17.9 (17.6-18.2) 57.4 (56.5-58.4) 17.4 (17.1-17.7) 8 206 18.1 (17.8-18.4) 55.1 (54.2-55.9) 16.9 (16.6-17.2)
18.0 (14.0-25.0) 56.0 (45.0-84.0) 17.0 (13.3-26.4) 18.0 (14.0-26.0) 54.1 (42.0-77.0) 16.3 (13.2-26.1)
9 224 18.7 (18.4-19.0) 60.2 (59.1-61.2) 18.0 (17.6-18.4) 9 188 18.5 (18.1-18.8) 56.5 (55.7-57.3) 17.1 (16.7-17.4)
18.5 (14.8-27.0) 58.9 (46.0-88.0) 17.5 (13.5-28.6) 18.2 (14.9-25.0) 56.0 (45.0-76.0) 16.9 (12.1-26.3)
10 216 19.1 (18.7-19.4) 60.9 (59.9-61.9) 17.9 (17.5-18.2) 10 227 19.5 (19.2-19.8) 59.5 (58.6-60.4) 17.9 (17.6-18.3)
19.0 (15.0-27.5) 60.0 (48.0-86.0) 17.5 (13.6-27.1) 19.2 (15.8-28.1) 58.0 (47.0-81.5) 17.5 (13.0-27.9)
11 176 20.1 (19.7-20.5) 64.1 (62.8-65.3) 19.0 (18.519.4) 11 188 20.4 (20.0-20.7) 60.8 (59.9-61.7) 18.5 (18.1-18.9)
20.0 (16.0-29.2) 62.2 (49.0-94.4) 18.2 (13.7-33.9) 20.0 (16.2-28.0) 60.0 (48.5-82.1) 17.0 (14.1-25.8)
12 195 20.8 (20.3-21.2) 65.6 (64.6-66.7) 19.2 (18.8-19.6) 12 193 21.0 (20.6-21.4) 62.5 (61.5-63.5) 19.5 (19.1-20.0)
20.5 (16.1-29.3) 64.2 (47.0-90.2) 18.6 (14.4-29.0) 21.0 (16.3-29.3) 62.0 (50.0-89.0) 18.8 (13.4-33.3)
13 190 21.2 (20.7-21.5) 67.4 (66.2-68.5) 19.4 (19.0-19.8) 13 196 21.7 (21.3-22.0) 64.0 (63.1-64.9) 19.9 (19.5-20.3)
21.0 (16.4-30.3) 65.6 (52.0-97.0) 19.2 (14.4-30.3) 21.3 (13.5-34.3) 63.0 (49.0-94.0) 19.2 (15.1-31.7)
14 256 22.1 (21.6-22.4) 70.6 (69.5-71.7) 20.5 (20.2-20.8) 14 333 22.8 (22.4-23.0) 66.6 (65.9-67.3) 21.0 (20.6-21.3)
22.0 (16.7-32.0) 69.1 (52.0-99.0) 19.8 (14.7-32.5) 22.6 (17.8-34.0) 66.0 (53.5-88.0) 20.5 (13.9-33.6)
15 387 22.8 (22.4-23.1) 72.1 (71.3-72.9) 21.1 (20.8-21.4) 15 410 22.5 (22.3-22.8) 66.9 (66.3-67.6) 21.4 (21.1-21.7)
23.0 (17.0-35.0) 71.0 (56.0-104.5) 20.5 (15.4-31.2) 22.4 (10.0-32.0) 66.0 (54.0-97.0) 20.9 (15.2-35.0)
16 287 23.2 (22.7-23.5) 72.2 (71.1-73.1) 21.0 (20.6-21.4) 16 353 22.9 (22.5-23.1) 67.1 (66.4-67.7) 21.6 (21.3-22.0)
23.0 (17.7-35.0) 71.0 (54.0-102.0) 20.6 (13.7-35.2) 22.5 (18.0-31.5) 66.0 (55.0-88.5) 21.1 (16.0-32.2)
17 162 23.7 (23.0-24.0) 73.5 (72.3-74.8) 21.3 (20.9-21.8) 17 151 23.0 (22.5-23.3) 66.3 (65.3-67.3) 21.6 (21.1-22.1)
23.2 (10.5-35.0) 73.5 (56.0-103) 20.8 (16.1-30.2) 22.5 (19.0-31.5) 65.0 (52.0-90.0) 21.1 (15.9-32.9)
WC: waist circumference, MUAC: mid-upper arm circumference , BMI: body mass index
* Age indicates one-year age group, e.g. 6.0-6.99 years, etc.
‡ Med (min-max): Median (minimum-maximum).
† Mean (95% Confidence Interval); χ(95%CI)
-----
-
-

This study aimed to evaluate 1) the role of WC and
MUAC, used in addition to BMI, in determining overweight and
obesity, 2) to establish cut-off values for defining overweight
and obesity with WC and MUAC (overweight and obesity are
defined according to BMI).
Methods
The data analyzed in this study were based on
measurements obtained in a study entitled “Determination
of Anthropometric Measures of Turkish Children and
Adolescents” (DAMTCA I) and conducted in the time
period from February to April 2006 (8). Children and adolescents
residing in Kayseri, Turkey constituted the study sample.
Kayseri province is a leading industrial and trade centre, which
has more than 1000 000 inhabitants and receives emigrants
from different parts of Turkey. Of a total of 5727 primary and
secondary school students included in the above-mentioned
study, data regarding WC, skinfold thickness and MUAC were
available in 2737 girls and 2621 boys, aged 6-17 years.
Methodology relating to sample selection, weight and height
measurements was given in the previous publication (8).
BMI (kg/m2) was calculated as weight (kg) divided by the
square of the height (m2). WC and MUAC were measured
to the nearest 0.1 cm with an anthropometric tape over light
clothing. WC was measured at the minimum circumference
between the iliac crest and the rib cage. MUAC measurements
were taken in centimeters with non-elastic tape to the nearest
0.1 mm on the upper left arm (halfway between the acromion
process and the olecranon process). The children/adolescent
stood relaxed with his/her side to the trained technician and the
arm hanging freely at the side; the tape was passed around the
arm at the level of the mid-point of the upper arm.
Results were presented as the mean 95% confidence
interval (95%CI), median, minimum-maximum (min-max)
for each age and gender. Simple linear regression analyses (R2)
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Maz›c›o¤lu MM et al.
Waist and Mid-Upper Arm Circumference
Table 2. ROC curve analysis of WC and MUAC in male children and adolescents for overweight cut-off values
Age (years) Variables AUC-ROC (95%CI)†Cut-off value P#Sensitivity Specificity
6 WC O.690 (0.601 - 0.770) 56.3* 0.930 42.3 83.7
MUAC 0.684 (0.595 - 0.765) 18.1* 50.0 88.9
7 WC 0.759 (0.695 - 0.815) 56.5** 0.228 64.4 79.1
MUAC 0.697 (0.630 - 0.759) 18.1** 57.8 79.8
8 WC 0.839 (0.780 - 0.888) 60.5** 0.247 66.0 94.0
MUAC 0.791(0.727 - 0.845) 18.9** 63.8 79.9
9 WC 0.903 (0.857 - 0.939) 61.5** 0.313 84.2 84.4
MUAC 0.873(0.822 - 0.913) 20.4** 68.4 97.6
10 WC 0.937 (0.896 - 0.965) 66.0** 0.953 85.3 92.9
MUAC 0.939 (0.898 - 0.967) 19.9** 97.1 76.9
11 WC 0.946(0.901 - 0.974) 66.7** 0.057 90.5 89.6
MUAC 0.891 (0.835 - 0.933) 21.9** 73.8 88.8
12 WC 0.944 (0.902 - 0.972) 68.6** 0.440 94.1 88.8
MUAC 0.919 (0.872 - 0.953) 21.9** 73.8 88.8
13 WC 0.965 (0.928 - 0.986) 72.5** 0.141 93.3 91.9
MUAC 0.919 (0.871 - 0.954) 22.6** 90.0 82.5
14 WC 0.924 (0.885 - 0.953) 71.9** 0.066 94.3 79.8
MUAC 0.874 (0.827 - 0.912) 22.8** 86.8 76.4
15 WC 0.912 (0.879 - 0.938) 76.7** 0.032 81.9 90.7
MUAC 0.852 (0.812 - 0.885) 24.9** 73.0 83.7
16 WC 0.952 (0.921 - 0.974) 73.8** 0.029 100.0 76.1
MUAC 0.884 (0.841 - 0.918) 24.2** 84.1 78.2
17 WC 0.967 (0.926 - 0.988) 78.3** 0.131 95.7 89.2
MUAC 0.898 (0.841 - 0.940) 25.7** 87.0 87.8
WC: waist circumference, MUAC: mid-upper arm circumference
† AUC-ROC (95% CI): area under ROC curve (95% CI)
# P: results of comparison of AUCs of WC, and MUAC for 6 age *(p<0.01)
# P: results of comparison of AUCs of WC, and MUAC for 7-17 ages **(p<0.001)

were computed to explore the relationships between BMI,
WC, and MUAC for each age.
The WC≥90th percentile values for age and gender were
used to identify children and adolescents with abdominal
obesity in accordance with the International Obesity Task Force
(IOTF) cut-off values for overweight and obesity (9). The
performance and cut-offs of anthropometric indices were
determined by the receiver operating characteristic (ROC)
analysis (10). The ROC curves demonstrated the overall
discriminatory power of a diagnostic test: BMI, WC, and
MUAC. The better test has a curve skewed closer to the upper
left corner. The area under the ROC curve (AUC) is a measure
of the diagnostic power of a test. The perfect test will have an
AUC of 1.0, while an AUC value of 0.5 indicates that the test
performs no better than expected by chance. Sensitivity and
specificity of the anthropometric indices have been calculated
at all possible cut-off points to find the optimal cut-off value.
The optimal sensitivity and specificity were the values yielding
maximum sums from the ROC curves (Clinical significance of
‘cut-off’s were checked with the Youden index). Cut-off values
and AUCs of WC and MUAC were compared for each age and
gender. MedCalc software was used to test the significance of
the differences for the AUCs.
Agreement between these anthropometric indices
were assessed by Cohen’s κstatistic, with values of 0.00
to 0.20 indicating poor, 0.21 to 0.40 - fair, 0.41 to 0.60-
moderate, 0.61 to 0.80-good, and 0.81 to 1.00 - excellent
concordance (11).
Results
The current study included 5358 subjects (2621 boys and
2737 girls). The mean and medians of WC and MUAC for each
age and gender are shown in Table 1. We determined the WC
cut-off values by relating WC and MUAC with BMI according to
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Maz›c›o¤lu MM et al.
Waist and Mid-Upper Arm Circumference
Table 3. ROC curve analysis of WC and MUAC in female children and adolescents for overweight cut-off values
Age (years) Variables AUC-ROC (95%CI)†Cut-off value P#Sensitivity Specificity
6 WC 0.744(0.658 - 0.817) 57.1* 0.135 38.7 94.7
MUAC 0.645 (0.555 - 0.728) 17.9** 67.7 75.8
7 WC 0.714 (0.639 - 0.781) 56.4** 0.898 60.0 84.0
MUAC 0.721 (0.646 - 0.787) 18.2** 60.0 83.2
8 WC 0.854 (0.798 - 0.899) 59.5** 0.817 76.3 93.5
MUAC 0.862 (0.808 - 0.906) 18.7** 80.8 75.0
9 WC 0.885 (0.831 - 0.927) 60.4** 0.900 76.7 85.4
MUAC 0.890 (0.837 - 0.931) 20.2** 76.7 90.5
10 WC 0.942 (0.903 - 0.969) 61.9** 0.067 93.8 85.5
MUAC 0.887 (0.838 - 0.925) 20.6** 81.3 86.0
11 WC 0.961 (0.923 - 0.984) 63.3** 0.131 92.1 88.7
MUAC 0.913 (0.864 - 0.949) 20.5** 94.7 68.7
12 WC 0.916 (0.868 - 0.951) 64.0** 0.679 92.9 84.1
MUAC 0.902 (0.852 - 0.940) 22.6** 73.8 89.4
13 WC 0.908 (0.859 - 0.945) 67.5** 0.369 82.4 84.6
MUAC 0.876 (0.821 - 0.919) 22.8** 85.3 82.7
14 WC 0.872 (0.832 - 0.906) 70.5** 0.900 68.2 90.6
MUAC 0.869 (0.828 - 0.903) 23.8** 84.5 76.4
15 WC 0.936 (0.908 - 0.958) 69.1** 0.267 92.2 83.8
MUAC 0.907 (0.875 - 0.934) 23.9** 89.1 81.5
16 WC 0.891 (0.854 - 0.922) 69.6** 0.250 85.3 81.2
MUAC 0.857 (0.816 - 0.892) 23.9** 82.0 78.1
17 WC 0.842 (0.774 - 0.897) 72.7** 0.141 57.1 96.2
MUAC 0.9131 (0.856 - 0.953) 24.5** 85.7 86.9
WC: waist circumference, MUAC: mid-upper arm circumference
† AUC-ROC (95% CI): area under ROC curve (95% CI)
# P: results of comparison of AUCs of WC, and MUAC
* (P<0.01), **(p<0.001)

the IOTF cut-off points. Since we could not find cut-off values
for MUAC in the relevant publications, we used WC≥90th
percentile as the cut-off value for the ROC analysis.
The AUC, cut-off value, sensitivity, and specificity for each
age and gender are shown in Tables 2-5. The AUC, both for WC
and MUAC, were statistically significant in both genders in the
age groups 6-17 years. The differences between AUCs for WC
and MUAC were not significant, indicating that both indices
performed equally well in predicting normal, overweight, and
obesity (except 15- and 16-year-old boys) in each gender in 6-17
years old children (Tables 2, 3).
The sensitivity of WC for 6-8 years old boys and the
sensitivity of MUAC for 6-8 and 15 years old boys were
estimated to be suboptimal for clinical use (Table 2).
The sensitivity of WC for 6,7,14,17 years old girls and
the sensitivity of MUAC for 6-7 years old girls were also found
suboptimal for clinical use (Table 3). The R2calculated
for R2showed that the values for BMI and WC were higher
than those for BMI and MUAC (Table 6).
The agreement between the two approaches (WC≥90th,
MUAC≥90th percentile) to define abdominal obesity
was moderate (κ=0.56, κ=0.50; p<0.001, respectively for
boys and girls).
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Maz›c›o¤lu MM et al.
Waist and Mid-Upper Arm Circumference
Table 4. ROC curve analysis to determine cut-off MUAC values for WC≥90th percentile in male children and adolescents
Age (years) AUC-ROC (95%CI)†Cut-off value # Sensitivity Specificity
6 0.755 (0.669 - 0.828) 18.2* 66.8 82.1
7 0.744 (0.679 - 0.802) 19.8** 52.6 93.6
8 0.862 (0.806- 0.907) 19.4** 70.0 86.9
9 0.926 (0.884 - 0.957) 20.9** 87.0 91.5
10 0.930 (0.888- 0.960) 21.2** 83.3 88.9
11 0.939 (0.892 - 0.969) 22.0** 88.2 86.8
12 0.912 (0.863 - 0.948) 21.7** 89.5 77.8
13 0.972 (0.937 - 0.990) 23.5** 100.0 88.3
14 0.954 (0.921 - 0.976) 24.3** 92.6 86.0
15 0.910 (0.877 - 0.937) 25.3** 81.4 89.2
16 0.928 (0.892 - 0.955) 26.0** 82.1 90.7
17 0.859 (0.795 - 0.908) 26.5** 72.2 92.4
WC: waist circumference, MUAC: mid-upper arm circumference
† AUC-ROC (95% CI): area under ROC curve (95% CI)
# AUCs of MUAC: Statistically significant (p<0.01)*, (p<0.001) **
Table 5. ROC curve analysis to determine cut-off values of MUAC for WC≥90th percentile in female children and adolescents
Age (years) AUC-ROC (95%CI)†Cut-off value # Sensitivity Specificity
6 0.840 (0.764 - 0.899) 18.0** 76.9 81.4
7 0.883 (0.824 - 0.928) 17.9** 100.0 63.3
8 0.946 (0.905 - 0.972) 20.1** 93.0 11.5
9 0.909 (0.858 - 0.946) 20.3** 88.2 87.1
10 0.893 (0.845 - 0.930) 22.3** 80.0 92.3
11 0.894 (0.841 - 0.934) 22.9** 72.2 89.4
12 0.905 (0.855 - 0.942) 21.9** 100.0 67.8
13 0.930 (0.884 - 0.961) 23.0** 95.0 85.2
14 0.927 (0.894 - 0.953) 24.1** 93.9 81.0
15 0.919 (0.889 - 0.944) 23.9** 95.1 77.8
16 0.926 (0.894 - 0.951) 44.3** 94.3 83.0
17 0.887 (0.825 - 0.932) 25.7** 69.2 90.6
WC: waist circumference, MUAC: mid-upper arm circumference
† AUC-ROC (95% CI), area under ROC curve (95% CI)
# AUCs of MUAC Statistically significant (p<0.001)**

Discussion
To the best of our knowledge this is the first and
comprehensive study discussing the use of different
anthropometric indices in evaluation of obesity in 6- to 17-year-
old children.
Increasing obesity prevalence among children and
adolescents is one of the leading public health problems
globally. Simple and practical methods are needed in screening
obesity. BMI is accepted as an index of body fat reserve, but
for the same BMI, body fat reserve may be different between
individuals. Another major drawback concerning BMI is that its
measurement gives no indication of body fat distribution. It has
been known for some time that a central distribution of body
fat, particularly an excess accumulation of fat intraabdominally
rather than a more peripheral distribution, carries a higher
risk for obesity-related comorbidities. Hence, WC is proposed
to describe body fat distribution as an index additional
to BMI. Laboratory-based methods (e.g. dual-energy X-ray
absorptiometry, underwater weighing) are also used to assess
body fat in children, but these methods are expensive and
usually limited to small-scale studies (12,13).
In this study, we measured MUAC in addition to WC
to describe obesity defined by BMI. We consider that each
country must determine their own cut-off values for WC, BMI,
and MUAC. While the use of BMI as a surrogate for fat excess
among children raises debates, WC is increasingly recognized
as a useful index reflective of both fat excess and risk of
diseases (14). Some anthropometric indices like WC and
MUAC, which are used to determine adiposity, show a good
level of correlation with corporal mass (15).
Early identification and treatment of children with central
adiposity is crucial to detect the risks for future metabolic
complications. WC is considered as the best
indicator of abdominal obesity, but in circumstances where
WC measurement is not feasible (skeletal deformities,
intraabdominal disorders or change in abdominal circumference
related with respiratory movements), measurement of
MUAC may be an alternative and reliable index. Thus,
anthropometric ndicators such as BMI, WC and MUAC can be
used as screening tools for obesity in children and adolescents
(16,17). However, systematic monitoring of WC and MUAC is
not a commonly performed method in pediatric studies in many
countries and internationally accepted cut-off values are also
not yet established.
WC rather than BMI is recommended as an index of
obesity-related health risks in adults (18,19). WC is a highly
sensitive and specific measure of truncal adiposity and a strong
predictor of visceral adiposity also in the pediatric population.
Furthermore, WC shows a relationship with the metabolic
consequences of obesity, including negative lipid profile,
increased blood pressure, and insulin resistance in children and
adolescents (20). In adults, specific WC cut-off values are
reported from different countries for screening metabolic
syndrome, cardiovascular diseases, type 2 diabetes and
hypertension, but studies describing specific WC cut-off values
in children are scarce (21,22,23).
MUAC is proposed as another important indicator of
obesity, and is also reported to closely reflect body fat tissue
(24). Analyzing the NHANES data, Gortmaker and Dietz
reported that while obesity prevalence was increased by 40%
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Maz›c›o¤lu MM et al.
Waist and Mid-Upper Arm Circumference
Table 6. Simple linear regression coefficients (R2) between WC, MUAC, and BMI in male and female children and adolescents
R2
Boys Girls
Age (years) WC-MUAC WC-BMI MUAC-BMI Age WC-MUAC WC-BMI MUAC-BMI
6 0.20 0.18 0.09 6 0.18 0.19 0.18
7 0.17 0.27 0.16 7 0.34 0.26 0.26
8 0.40 0.49 0.31 8 0.54 0.52 0.51
9 0.53 0.69 0.54 9 0.57 0.54 0.52
10 0.53 0.67 0.60 10 0.55 0.66 0.56
11 0.66 0.64 0.52 11 0.49 0.50 0.55
12 0.59 0.66 0.61 12 0.50 0.65 0.59
13 0.54 0.69 0.50 13 0.59 0.62 0.52
14 0.63 0.64 0.49 14 0.46 0.55 0.52
15 0.44 0.66 0.38 15 0.45 0.55 0.56
16 0.49 0.67 0.47 16 0.51 0.57 0.57
17 0.38 0.65 0.48 17 0.42 0.45 0.57
WC: waist circumference, MUAC: mid-upper arm circumference , BMI: body mass index
All correlation coefficients were statistically significant (p<0.001)

in a 20-year period, BMI values remained relatively constant
(25). This finding indicates that the proportion of body fat and
lean body mass have changed longitudinally.
Additionally, energy intake, growth, and fat storage
characteristics of children may also lead to discordance in
assessing overweight and obesity. Arm anthropometry appears
as a popular, cheap and non-invasive method. Especially in
epidemiologic studies, MUAC is a practical tool and can be
measured easily almost in any situation. The primary limitation
may be the absence of studies to determine the validity of this
method (25).
Finally, we believe that the primary contribution of this
present study was the finding that both WC and MUAC can be
substituted for one another as an additional evaluation tool
next to BMI in detecting overweight and obese children and
adolescents. It was found that in boys, clinically significant WC
cut-off values could be obtained at ages 9 to 17, while the
optimal ages to obtain MUAC cut-off values were 9-14 and
16-17 years (Table 2). Optimal ages to get clinically significant
WC and MUAC cut-offs in the girls were 8-13 years for WC and
15-16 years for MUAC.
In conclusion, our data revealed that both WC and
MUAC show a good correlation with BMI and that these two
parameters have the characteristic of indirectly defining the
composition (lean and fat tissue content) of the body rather
than providing information on total mass. We believe that the
present study contributes to providing cut-off values for two
practical tools, which can be used to determine body fat
reserve. Additionally, these two indices may also be used in
epidemiologic studies to assess cardiovascular and metabolic
risk in overweight and obese children.
Acknowledgments
The authors would like to thank the students of Kayseri
Health Institute for their valuable help in data collection and the
Erciyes University School of Medicine for their support.
References
1. Berenson GS, Srinivasan SR, Wattigney WA, For The Bogalusa
Heart Study Gerald S. Berenson, Sathanur R. Sr›n›vasan,
We›hang Bao, D, W›ll›am P. Newman I››. Obesity and
cardiovascular risk in childhood. Ann NY Acad Sci 1993;
699:93-103. [PDF]
2. World Health Organization Obesity: Preventing and Managing
the Global Epidemic. Report of the WHO Consultation
on Obesity: Geveva Switzerland; World Health Organization,
1998; 1-7.
3. Dietz WH. Childhood weight affects adult morbidity and
mortality. J Nutr 1998;128:411-414. [Abstract] / [Full Text] /
[PDF]
4. Chumlea WM, Guo SS. Assessment and prevalence of
obesity; application of new methods to a major problem.
Endocrine 2000;13:135-142. [Abstract] / [PDF]
5. de Onis M. The use of anthropometry in the prevention of
childhood overweight and obesity. Int J Obes Relat Metab
Disord 2004;28:81-85. [Full Text] / [PDF]
6. Al-Sendi AM, Shetty P, Musaiger AO. Anthropometric and
body composition indicators of Bahraini adolescents. Ann Hum
Biol 2003;30:367-379. [Abstract] / [PDF]
7. Cook S, Weitzman M., Auinger P, Nguyen M, Dietz WH.
Prevalence of a metabolic syndrome phenotype in
adolescents. Arch. Pediatr Adolesc Med 2003;157:821-827.
[Abstract] / [Full Text] / [PDF]
8. Hatipo¤lu N, Kurto¤lu S, Öztürk A, Maz›c›o¤lu MM. The weight
and height percentiles in 6-18 year old children in Kayseri and
comparison with Istanbul data. J Clin Res Ped Endo 2009;
1:129-135. [PDF]
9. Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a
standard definition for child overweight and obesity worldwide:
international survey. BMJ 2000;320:1240-1243. [Abstract] /
[Full Text] / [PDF]
10. Metz CE. Basic principle of ROC analysis. Semin. Nucl Med
1978;8:283-298. [Abstract] / [PDF]
11. Landis JR, Koch GG. The measurement of observer agreement
for categorical data. Biometrics 1977;33:159-174. [Abstract] /
[PDF]
12. Moreno LA, Blay MG, Rodriguez G, Blay VA, Mesana MI,
Olivares JL, Fleta J, Sarría A, Bueno M; AVENA-Zaragoza Study
Group. Screening performances of the International Obesity
Task Force body mass index cut-off values in adolescents. J
Am Coll Nutr 2006;25:403-408. [Abstract] / [Full Text] / [PDF]
13. Rodriguez G, Moreno LA, Blay MG, Blay VA, Garagorri JM,
Sarría A, Bueno M. Body composition in adolescents;
measurements and metabolic aspects. Int J Obes Relat Metab
Disord 2004;28:54-58. [Abstract] / [Full Text] / [PDF]
14. Goran MI, Allison DB, Poehlman ET. Issues relating to
normalization of body fat content in men and women. Int J
Obes Relat Metab Disord 1995;19:638-643. [Abstract]
15. Jelliffe EF, Jelliffe DB. Anthropometry in action. I. Dental
second year malnutrition. (Practical age-grouping in young
children in areas without birth verification). J Trop Pediatr 1968;
14:71-74. [Abstract]
16. Pouliot MC, Despres JP, Lemieux S, Moorjani S, Bouchard C,
Tremblay A, Nadeau A, Lupien PJ. Waist circumference and
abdominal sagittal diameter; best simple anthropometric
indexes of abdominal visceral adipose tissue accumulation and
related cardiovascular risk in men and women. Am J Cardiol
1994;73:460-468. [Abstract]
17. Rankinen T, Kim SY, Perusse L, Després JP, Bouchard C.
The prediction of abdominal visceral fat level from body
composition and anthropometry; ROC analysis. Int J Obes
Relat Metab Disord 1999;23:801-809. [Abstract] / [PDF]
18. Kelishadi R, Ardalan G, Gheiratmand R et al. Paediatric
metabolic syndrome and associated antropometric indices; the
Caspian study. Acta Pediatrica 2006;12:1625-1634. [Abstract] /
[PDF]
19. Eisenmann JC. Waist circumference percentiles for 7- to
15-year-old Australian children. Acta Paediatr 2005;94:1182-
1185. [Abstract] / [PDF]
20. Fredriks AM, van Buuren S, Fekkes M, Verloove-Vanhorick SP,
Wit JM. Are age references for waist circumference, hip
circumference and waist-hip ratio in Dutch children useful in
clinical practice? Eur J Pediatr 2005;164:216-222. [Abstract] /
21. Hatipoglu N, Ozturk A, Mazicioglu MM, Kurtoglu S, Seyhan S,
Lokoglu F. Waist circumference percentiles for 7- to 17-year-
old Turkish children and adolescents. Eur J Pediatr 2008;
167:383-389. [Abstract] / [Full Text] / [PDF]
22. Katzmarzyk PT. Waist circumference percentiles for Canadian
youth 11-18y of age. Eur J Clin Nutr 2004; 58:1011-1015.
[Abstract] / [Full Text] / [PDF]
23. McCarthy HD, Jarrett KV, Crawley HF. The development
of waist circumference percentiles in British children aged
5.0-16.9 y. Eur J Clin Nutr 2001;55:902-907. [Abstract] / [PDF]
24. Chomtho S, Fewtrell MS, Jaffe A et al. Evaluation of arm
anthropometry for assessing pediatric body composition;
evidence from healthy and sick children. Pediatr Res 2006;
59:860-865. [Abstract] / [Full Text] / [PDF]
25. Gortmaker SL, Dietz WH Jr. Secular trends in body mass index
in the United States, 1960-1980 (letter). Am J Epidemiol 1990;
132:194-195. [Abstract]
150
Maz›c›o¤lu MM et al.
Waist and Mid-Upper Arm Circumference
[Full Text] / [PDF]