Dr. David McCarthy RNutr Institute of Health Research & Policy London Metropolitan University 28 th March 2004 Body Mass Index (BMI) in adults - affected minimally by age popular, quick, use fixed cut-off points in children - greatly affected by age Drawbacks of BMI in children Age-dependent Correlates with both fat mass and fat-free mass Low sensitivity no indication of body fat distribution Cannot identify secular trends BMI 40 30 20 10 F a t
M a s s
( k g ) 40 30 20 10 0 Correlation of BMI with Fat Mass (kg) r 2 = 0.763, P<0.0001 16-18 year olds BMI 40 30 20 10 F a t
F r e e
M a s s
( k g ) 80 70 60 50 40 30 Correlation of BMI with Fat Free Mass (kg) r 2 = 0.514, P<0.0001 16-18 year olds Cut-off points US 85 th and 95 th centiles UK 91 st and 98 th centiles IOTF centiles relating to BMI of 25 and 30 at age 18 years IOTF obese IOTF overweight Childhood prevalence in the UK Obese 17% (BMI >95 th centile) Overweight 31% (BMI >85 th centile) Source: Reilly et al. 1999 Assessment requirements in children Simple measurement technique Strongly related to morbidity or risk (CHD) Biological/clinical definition Avoid misclassification Waist circumference in adults Indicator of intraabdominal fat related to risk for NIDDM, hypertension and CVD waist:hip and waist:height ratios Central body fat accumulation in children Intra-abdominal adipose tissue Subcutaneous abdominal adipose tissue assessed by girth and skinfold measurements Is waist circumference in children linked to risk? WC related to an adverse atherogenic lipoprotein profile in 12-14 year olds (Flodmark et al. 1994) WC related to adverse insulin concentration in 5-17 year olds (Bogalusa Heart Study, Freeman et al. 1999) Waist circumference and blood pressure Jarrett, McCarthy et al. (unpublished observations, 2002), 4 and 5 year olds) The Metabolic Syndrome WC percentile charts in children Italian children (Zannolli & Morgese 1996) Spanish children (Moreno et al. 1999) Cuban children (Martinez et al. 1994) British children (McCarthy et al. 2000) Waist circumference measurement Midway between the 10 th rib and the iliac crest WHO standard method Used by : McCarthy et al. 2000 Freedman et al. 1999 Moreno et al. 1999 Waist circumference measurement continued. At the level of the umbilicus Used for the waist circumference percentiles in Italian children, Zanolli et al. 1996 UK children's study 8355 children aged 5-17 years mean and SD for waist circumference smoothed percentile curves constructed using the LMS method (Cole 1990) 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Age (years) 40 50 60 70 80 W a i s t
c i r c u m f e r e n c e
( c m ) Boys Girls Waist in children n, 8355 McCarthy et al. 2001, EJCN Development of WC centile charts for the UK children 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Age (years) 40 45 50 55 60 65 70 75 80 85 90 95 100 W a i s t
c i r c u m f e r e n c e
( c m ) 40 45 50 55 60 65 70 75 80 85 90 95 100 99.6 98 91 75 50 25 9 2 0.4 Boys 3-17 y D.McCarthy2001 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Age (years) 40 45 50 55 60 65 70 75 80 85 90 95 100 W a i s t
c i r c u m f e r e n c e
( c m ) 40 45 50 55 60 65 70 75 80 85 90 95 100 99.6 98 91 75 50 25 9 2 0.4 Girls 3-17 y D.McCarthy2001 What about clothing effects? Preferable to measure over skin need to take account of vest, T-shirt or school shirt subtract 0.5 cm from reading problem in measuring over tunics Waist Girth WsGr 70 60 50 40 B M I 22 20 18 16 14 12 Boys aged 6.0-6.99 y p<0.01 r 2 =0.689 n=349 Waist circumference vs BMI Waist Girth WsGr 80 70 60 50 40 B M I 24 22 20 18 16 14 12 10 Girls aged 6.0-6.99 y p<0.01 r 2 =0.716 n=400 Waist circumference vs BMI BMI-WC relationship Subject Age BMI WC BMI %ile WC %ile (y) (cm) A 7.7 15.2 48 ~50th <9th B 7.5 15.3 65 ~50th >98th C 7.1 19.1 53 >91st ~50th D 7.1 20.0 67 >98th >99.6th BMI-WC relationship Subject Age BMI WC BMI %ile WC %ile (y) (cm) A 14 19.3 66 ~50th ~40th B 14 19.3 85 ~50th ~98th C 14 21.7 65 ~85th ~30th D 14 28 94 >98th >98th Source - NDNS Young People aged 4 to 18 yrs, Gregory & Lowe, 2000) Has upper body fatness increased in British children? Comparison of data collected 10 and 20 years apart BSI and NDN surveys 10 11 12 13 14 15 16 17 Age group (years) 58 62 66 70 74 78 82 W a i s t
c i r c u m f e r e n c e
( c m ) ** ** ** ** ** ** ** ** ** ** ** ** McCarthy et al. 2003. BMJ 326: 624 NDNS boys NDNS girls BSI boys BSI girls 10 11 12 13 14 15 16 Age group (years) 17 18 19 20 21 22 23 24 B o d y
M a s s
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( k g / m 2 ) * * * + * * * * * * * * McCarthy et al. 2003. BMJ 326: 624 NDNS girls NDNS boys BSI girls BSI boys Changes over 10-20 years in overweight and obesity based on BMI and waist circumference in British children aged 11- 16 years. Values are % exceeding 91 st centile (98 th centile) % prevalence of overweight % change (obesity) over time BSI 1977/87 NDNS 1997 Male Female Male Female Male Female BMI 7.7 5.9 20.6 17.3 12.9 11.4 (3.3) (1.6) (10.0) (8.3) (6.8) (6.6) WC 8.7 8.8 28.5 38.1 1 9.8 29.3 (3.3) (3.1) (13.8) (17.1) (10.7) (14.5) McCarthy et al. 2003. BMJ 326: 624 Changes over 10-20 years in mean BMI and waist circumference in British children aged 11-16 years. Mean SD Score (SD) Mean increase over time (SE) BSI 1977/87 NDNS 1997 Male Female Male Female Male Female BMI -0.05 -0.15 0.42 0.38 0.47 0.53 (1.02) (0.99) (1.13) (1.09) (0.06) (0.06) WC 0.00 0.00 0.84 1.02 0.84 1.02 (0.99) (1.00) (1.02) (1.33) (0.06) (0.06) McCarthy et al. 2003. BMJ 326: 624 How should I use the WC percentile charts? In conjunction with BMI centile charts as a second line point of reference for referral routinely epidemiology research Further issues Cut-off points yet to be linked to risk or Fat Mass What effect does measurement error have upon validity of WC percentiles? Relationship between BMI and WC centile Conclusions Waist circumference important in children Simple technique WC correlates with risk factors for CHD further work required on validation of technique other countries could begin to develop WC percentiles in their childhood population Genetics Prenatal diet Leg length? Infant feeding Current diet Physical activity central obesity Catch-up growth Acknowledgements Karen Jarrett Adam Collins Prof. Tim Cole Sandra Ellis Pauline Emmett Jean Golding and the ALSPAC team