Published online August 31, 2009
PEDIATRICS
Vol. 124
Supplement
September 2009, pp.
S42-S49
(doi:10.1542/peds.2008-3586G)
BMI Screening and Surveillance: An International Perspective
William Philip Trehearne James, MD, DSca,b and
Tim Lobstein, PhDb,c,d
a Department of Nutrition, London School of Hygiene and Tropical Medicine, London, United Kingdom
b International Obesity Taskforce, London, United Kingdom
c University of Sussex, Brighton, United Kingdom
d Rudd Center for Food Policy and Obesity, Yale University, New Haven, Connecticut
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ABSTRACT
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International efforts to screen children have previously focused
on the problem of malnutrition in the preschool years. The new
World Health Organization–derived but US-based data for
"optimum" growth in school-aged children may not be accepted
in more than a few countries. Currently, an international perspective
suggests that those school-aged children's BMIs that, on a percentile-ranking
basis, track to adult BMIs of
25 kg/m
2 are likely to be associated
with an appreciable increased risk of the comorbidities associated
with weight gain. There is limited evidence on the value of
individually directed help for children with higher BMIs as
a national policy, but national surveillance systems are badly
needed to allow a better focus on the development of both public
health and individual treatment policies.
Key Words: growth • obesity • children • surveillance
Abbreviations: WHO—World Health Organization • IOTF—International Obesity Taskforce • CDC—Centers for Disease Control and Prevention • NHANES—National Health and Nutrition Examination Survey • LBW—low birth weight
The monitoring of childhood growth has, perhaps surprisingly, been a contentious issue for several decades. This global debate has reflected the disparate views of pediatricians who, when using the "reference" curves established by the World Health Organization (WHO) and based on the best data then available, observed that these data were classifying children in their own countries as well below the curves. Despite these reservations, immense efforts were made, particularly in Africa, to establish these growth charts as the legitimate vehicle for monitoring good health. Much of the effort was led originally by Jelliffe in Uganda1 and then by Morley and Cutting2 of the Institute of Child Health (London, United Kingdom).
In the early 1970s, epidemiologic analyses in the Caribbean island of Montserrat led us to recognize the dominant role of stunting in explaining the low weight for age of the majority of the world's children. Malnutrition was specified when the height, weight, or weight-for-height values were <2 SDs of the reference means for boys and girls of the appropriate age.3 This approach was reaffirmed in the 1995 WHO analyses of the usefulness of anthropometric assessments of nutritional status.4
With the almost exclusive focus on the growth of preschool-aged children as the most vulnerable group, there has been relatively little information on the growth of school-aged children in most parts of the world. Thus, in the assessment of children's malnutrition and obesity for the WHO's first-ever analyses of the risk factors associated with the global basis of disease and disability, de Onis et al5 were able to provide extraordinarily comprehensive analyses of children's growth from birth to 5 years. However, when considering obesity in children older than 5 years, we had little option but to use occasional national surveys, sometimes extrapolate from small-scale ad-hoc studies to national estimates, and (often in Africa in particular) give a crude estimate on the basis of neighboring country data.6
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THE USE OF BMIs IN MONITORING CHILDREN'S GROWTH
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When the International Obesity Taskforce (IOTF) produced its
draft on obesity for the first WHO consultation on obesity just
over 10 years ago, there was no robust international system
for considering obesity in children. Dietz and Bellizzi
7 in
the IOTF children's group therefore considered the issue in
detail and agreed to use the BMI values, although the Benn index
p in the measure weight/height to the power
p chosen as 2.0
(ie, similar to the Quetelet index in adults [ie, BMI, weight
(kg)/height (m)
2]) should have been changed on a yearly basis
if the objective was to have a height-independent measure of
body size.
8 Relating skinfold thickness to Benn values of
2.0
in the weight/height
p index was reasonable except for children
aged 12 to 16 years. For these children the optimal values for
n were higher. Overall, the use of BMI as an indicator of adiposity
seemed acceptable for children aged 6 to 7 and 17 to 18 years
(see Fig
1). However, a Benn index of 2.0 means that taller
children, particularly at 6 to 12 years of age, have higher
prevalences of obesity
9 (Fig
2). This has often been observed
and led to the conclusion that children who grew tall earlier
were those most likely to become overweight and obese. This
is true if subsequent obesity is observed in adults but may
be confounded by the fixed Benn index of 2.0 if assessed in
earlier years.
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FIGURE 1 Benn index values fitting skinfold measures best in 2 surveys of US white boys.8 The graph shows the optimum value of the power p in the equation weight (kg)/height (mp) when the same average values for the weight/height index for children of different heights are obtained and applied to 2 US national cross-sectional surveys. NHES indicates National Household Education Surveys. (Reproduced with permission from Franklin MF. Comparison of weight and height relations in boys from 4 countries. Am J Clin Nutr. 1999;70(1):161S.)
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FIGURE 2 The prevalence of obesity in white US boys of different height: impact of a Benn index of 2.0.8 Note that the prevalence of obesity is based on the proportion of children at each age who exceeded the 85th percentile of BMI derived from US children in the National Health and Nutrition Examination Survey I as presented by Must et al.9 The 3 different groups relate to the 3 tertiles of height observed in the survey. If height had little or no effect on the prevalence of obesity as determined by a weight/height index to the power 2.0, then the proportions of boys exceeding the 85th percentile should be roughly equal for all height categories and age groups. (Reproduced with permission from Franklin MF. Comparison of weight and height relations in boys from 4 countries. Am J Clin Nutr. 1999;70(1):161S.)
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The IOTF group then developed BMI reference values
10 based on
the data from nationally representative surveys of 6 countries:
Brazil, United States, United Kingdom, Netherlands, Singapore,
and Hong Kong. These derived IOTF values for the mean of the
appropriate percentiles are now used almost universally for
quantifying the prevalence of overweight and obesity across
the world.
11 They have also been assessed in relation to estimates
of impedance measurements of body fat in UK children. The IOTF
values were found to be very satisfactory at the lower overweight
cutoff point but not so robust at the obesity cutoff values
(see Table
1).
12
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TABLE 1 Sensitivity and Specificity of Overweight and Obesity Based on the IOTF BMI Cut-off Points for Boys and Girls and Based on Impedance Estimates of Body Fat
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NEW STANDARD (THAT IS, "IDEAL" GROWTH CHARTS): COMPARISONS WITH THE CENTERS FOR DISEASE CONTROL AND PREVENTION CHARTS
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The 1990 WHO reference values were derived from the US National
Center for Health Statistics set of reference charts of 1977,
which reflected the growth of predominantly bottle-fed infants.
The new WHO study involved breastfed infants and children from
California, Norway, India, Oman, Ghana, and Brazil. They showed
that, despite the different ethnic backgrounds, the children's
growth was almost identical and the variability in growth was
far less than in the databases normally used for producing growth
charts. If one takes the new WHO ±2 SD values as the
limits of normality, then the estimated prevalences of underweight
and overweight will now be greater, particularly in terms of
overweight, because in both children and adults there is an
increasingly skewed distribution of weights as the average weight
for age rises. Thus, overweight rates increased by one third
when the new WHO standard curves were used rather than the old
National Center for Health Statistics data; there were also
far more infants and 1-year-olds classified as stunted.
13
The new set of growth curves from the WHO is being considered as the ideal growth pattern for children up to 5 years from any ethnic group, but this is at variance with policies in many countries in which governments still assume that their children grow differently for genetic or other reasons particularly in their height trajectories. The Centers for Disease Control and Prevention (CDC) has produced its own growth curves. However, comparing the new WHO charts with the CDC charts for children younger than 5 years shows that the CDC curves show their "normal" children to be heavier and shorter than the WHO-measured children, particularly during the first year.14
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THE IDEAL GROWTH OF SCHOOL-AGED CHILDREN
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In late 2007, the WHO set out their estimates of the growth
of children from 5 to 20 years of age.
15 Surprisingly, these
are once more based exclusively on US data despite detailed
examination of other growth curves from many international sources.
Although specified as "reference" curves for those older than
5 years, the melding of the preschool- and school-aged curves
implies that the world's children, if optimally fed and nurtured,
should in theory grow in line with a subset of the cohort of
US children of old. What is already clear, however, is that
far more children in population surveys will now be designated
as overweight. In fact, the cutoff points chosen are very close
to those percentiles chosen for the IOTF analyses at the age
of 18 to 20 years, but there are appreciable differences in
the actual BMI values between the different estimates at younger
ages (see Fig
3).
Therefore, there are now 3 cutoff systems in widespread use:
- the 2000 CDC reference curves at the 85th and 95th percentiles;
- the IOTF BMI 25 and BMI 30 percentile-equivalent cutoffs; and
- the 2007 WHO growth curves with first and second SD limits.
The data in Fig 3 show that the IOTF cutoff for obesity is much higher than that in the CDC and WHO curves, and these 2 latter curves almost overlap. However, the IOTF overweight curves almost match the 85th CDC percentile curves, but the new WHO curves for +1 SD present much lower cutoff points. The application of the WHO criteria would increase the prevalence of those classified as "overweight" in IOTF terms and those considered "at risk of overweight" in CDC and WHO terminology. Table 2 uses data from the latest National Health and Nutrition Examination Survey (NHANES) of children and presents the prevalence of overweight and obesity estimated by the 3 different criteria. The new WHO criteria give the highest prevalence of overweight (including obesity), with the IOTF system being the most conservative in the younger group of 6- to 11-year-old boys. In general, however, the CDC and IOTF give similar values, but the WHO system increases the prevalence by 10% to 15%. As in previous analyses, the prevalence of obesity by the IOTF cutoff scheme is substantially lower than that by the CDC method, but now the CDC and WHO figures for this extreme group are similar.
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TABLE 2 Prevalence of Overweight (Including Obesity) and Obesity in School-aged US Children (NHANES 2003 and 2004 Combined)
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INTERNATIONAL VALIDITY OF THE CDC AND WHO CURVES
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Given that the database for the WHO curves implies "near-perfect"
growth, it is logical to consider those school-aged children
and adolescents within the upper end of the BMI distribution
as having healthy weights. However, the 15% of children above
the 85th percentile would, on an IOTF basis, be considered as
likely to be unhealthy. It is difficult to conclude, on the
basis of current evidence, that the approach adopted by the
WHO is wise from a public health point of view. There is substantial
evidence from US adult data that BMIs of
25 are associated with
marked morbidity. For decades we have also known that the earlier
the excess weight is evident, the greater the long-term risk,
and now new evidence has revealed that modest increases in the
BMIs of 7- to 13-year-olds in Denmark (ie, with genetic stock
reasonably similar to that of US whites) predict early death
and cardiovascular disease.
16 Passing through the centiles to
greater degrees of overweight is a powerful predictor of future
morbidity. So, from a US point of view one has to recognize
that if children in the higher percentiles of BMI with their
known associated comorbidities
17 maintain their higher BMIs
into adult life, then their health is likely to be compromised.
On an individual basis there do not seem to be any illuminating
analyses of the absolute risk for these children in terms of
disability and premature death that can be used to inform pediatricians,
but the public health dimension that relates to future health
costs on a national basis and the implications for the economy
of the country demands a different perspective.
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ETHNIC ISSUES
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With the Mexican government in their nationally representative
survey in 2000, which compared with age- and gender-matched
non-Hispanic US whites, we showed that Mexicans had a greater
prevalence of type 2 diabetes and hypertension as BMI increased
and a greater propensity for abdominal obesity. In our WHO global
burden analyses
6 we also found in nationally representative
data that the Japanese were 2 to 5 times more prone to type
2 diabetes than Scandinavians, and we have now confirmed this
with major data sets comparing Asian and white populations.
White people are far less prone to hypertension and type 2 diabetes
than Asian people for equivalent gains in BMI, and there seems
to be an absolute increase in these morbid conditions even at
low BMIs.
18 It is little wonder, therefore, that Asian countries
in general take an upper-normal limit of BMI at 23 as appropriate
(with the Chinese deriving a value of 24 on the basis of different
criteria). Given this perspective, Yap in Singapore has suggested,
quite reasonably, that the upper percentile chosen for the normality
of children's BMIs should be reduced to the percentile corresponding
with an adult BMI of 23. Her data,
19 together with that of Deurenberg
et al
20 and of Yajnik
21 from India, suggest that these ethnic
differences in disease susceptibility may relate, in part, to
different proportions of body fat. Yajnik has shown increasingly
impressive evidence in favor of early epigenetic and other programming
effects of the mother's nutritional state in pregnancy. His
analyses also highlight the marked increases in risk factors
of faster-growing Indian children resulting in greater BMI.
These findings amplify the concern about the international relevance
of US-based curves as ideal measures for more susceptible children
in the world (ie, the majority of the world's children).
In late 2007, assessments of the health burden in the Caribbean, as part of a Pan American Health Organization/Caribbean Prime Ministers' initiative, also showed that diabetes and hypertension prevalences were in excess of those expected for the degrees of obesity observed. Caribbean immigrants currently in the United States are probably also very susceptible to the comorbidities of obesity even if those from much earlier generations are not.
These differences may have a genetic origin, although on the basis of extensive new data from the developing world and Scandinavia it is more likely that we are dealing with marked epigenetic and programming phenomena relating to the population's adverse fetal and infant environment.22
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PREDICTING THE RISK ASSOCIATED WITH DIFFERENT RATES OF CHILDHOOD GROWTH
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The classic Barker et al
23 analyses of English adults with hypertension,
diabetes, and abdominal obesity (characteristics of what was
then called syndrome X and is now called metabolic syndrome)
showed that the birth weight of these individuals was an important
predictor of their ill health. Similar results are now evident
in many countries including the United States,
24 Guatemala,
Finland, China, and India. If the children are of low birth
weight (LBW), then as shown in our Millennium analyses for the
United Nations,
25 their likelihood of being underweight for
age in the first few years of life is exceptionally high, because
children would have to show accelerated growth from birth to
be classified otherwise. Table
3 shows in young Finnish adults
26 that, as in the British subjects of Barker et al
23, the children's
risk of adult-onset diabetes was most evident when small newborn
infants gained more weight than usual and were heavy at 12 years
of age. Detailed Indian data
27 provide roughly similar data
in relation to both glucose intolerance and diabetes. The optimum
prediction was evident if children were of lower weight at 2
years but subsequently gained excess weight so that they were
heavy by the age of 12 years (Table
4). These data suggest that
it is the disjunction between the early setting of growth rates
and later accelerated weight gain that is particularly harmful.
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TABLE 3 Cumulative Incidence of Diabetes in Finnish Adults Aged 27 to 37 Years According to Their Birth Weight and BMI at the Age of 12 Years26
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TABLE 4 Prevalence of Adult Glucose Intolerance and Diabetes in Indians Aged 26 to 32 Years in Relation to Their BMIs When 2 and 12 Years and Then Taking Account of Their Adult BMI Status27
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It is noteworthy that, originally, small Indian children who
had a BMI at >16 when 12 years of age already had about double
the risk of developing diabetes (about one third of the numbers
with both diabetes and glucose intolerance) than the LBW Finns.
This susceptibility probably relates to the unusual early insulin
resistance (from birth) of these Asian children,
28 which is
increasingly linked to vitamin B
12 deficiency in the mother
during pregnancy. Vitamin B
12 deficiency is also evident in
Mexico, for example. Hypertension and insulin resistance with
type 2 diabetes occur earlier in Asians, who show a 3- to 5-times
greater diabetes rate at the same adult BMI
17 when compared
with Australasians, for example. The latest analyses of LBW
prevalence by the WHO and the United Nations Children's Fund
29 showed that the LBW prevalences around the year 2000 were
28%
in Asia (India, Bangladesh, Nepal, Sri Lanka, and the Philippines),
15% in sub-Saharan Africa, 15% in the Middle East and North
Africa, and 9% in the Asia-Pacific and Latin American-Caribbean
regions. However, current adult morbidity rates relate to much
higher prevalences of LBW and stunting when these adults were
children 40 to 70 years ago.
Given these findings, one can surmise that when school-aged US children are found to have a high BMI (eg, >85th percentile), they are at an increased risk of premature morbidity and mortality whatever their racial origin. If, however, the child was also born small or had a low BMI in their first 2 years of life, then their likelihood of having diabetes is increased approximately twofold. If the child is of Asian, Hispanic, or Caribbean origin, then there is another twofold to fivefold increased risk of adult disease, with the most vulnerable group probably being those of Indian descent whose family still follows a vegetarian diet. These propositions now need to be supported by new analyses undertaken in a standardized format so that the risks of overweight and obese children from different ethnic groups can be set out in a more coherent manner.
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INTERNATIONAL SCREENING AND SURVEILLANCE
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The UK government and the London Royal College of Child Health
originally opposed the introduction of BMI screening of children
at school because there seemed to be no good case to show that
there were valid and cost-effective remedial measures that would
justify the effort and expense. The policy was to only introduce
a measure for medical screening if there was substantial and
clear evidence of effective remedial action to justify the effort
involved. At that time there were also remarkably few pediatricians
in the United Kingdom who had any experience with helping overweight
children effectively.
The routine surveillance of children, however, was considered a different issue in the United Kingdom, and the government opted for a national randomly sampled annual survey with measurements of children and adults. This is now routinely undertaken.
More recently, considerable political pressure to reintroduce BMI screening of children has led to a system in which parents give permission for their children to be monitored. Recent analyses have shown that parents of obese children opt out of the measurement system. The details of what will be involved in the government initiative are still unclear.
In Singapore, a very different approach was introduced in 1993, with a legal requirement for all children to be screened annually. Those in the upper range of BMI were required to stay after school and to eat separately in a different canteen for lunch, and the parents were alerted and required to change the eating patterns of their children. The schools themselves were disadvantaged financially if they sent children for the compulsory conscription medical examination who were found to be obese. The initiative, organized by the Ministry of Education led by the prime minister with all ministers and head teachers, involved extensive training of every teacher in the country to reinforce the message. The initiative initially had a dramatic effect on the prevalence rates of obesity (Fig 4) but was stopped in early 2007 after political lobbying by parents who felt that their children were being disadvantaged by, for example, the stigma of having to stay after school to exercise and eating in a separate canteen. International evidence on the importance of genetics in explaining a substantial part of the interindividual variation in BMIs within a community reinforces the need for care in selectively targeting overweight children. A more holistic approach for the whole school is now being developed in Singapore, but what this means in practice is still unclear.
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FIGURE 4 Prevalence of obesity in Singaporean school-aged children: weight (kg) for height (m) > 120% (new growth charts used since 1994). Source: Ministry of Health, Singapore (Yap M, personal communication).
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CONCLUSIONS
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International efforts to screen children previously focused
on the problem of malnutrition in the preschool years. The new
WHO data for those younger than 5 years, based on data from
breastfed children, are now considered optimum for all ethnic
groups. US-based data for the growth in school-aged children
may not be accepted easily even as reference data; an international
perspective suggests that those school-aged children whose BMIs
on a percentile-ranking basis track to adult BMIs of >21
are likely to have a progressive increased risk of the comorbidities
associated with weight gain in adolescence/early adult life
and with premature death. The 15% whose
85th percentiles track
to adult BMIs of
25 are clearly at greater risk. There is limited
evidence on the value of individually directed help for children
with higher BMIs as a national policy except in Singapore, where
this very interventionist approach has now been changed to avoid
overweight children and their families being classified as failing
to respond to the government's initiatives.
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FOOTNOTES
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Accepted Apr 29, 2009.
Address correspondence to William Philip Trehearne James, MD, DSc, International Obesity Task Force, IASO Office, Lower Ground Floor, 28 Portland Place, London W1B 1LY, UK. E-mail: JeanHJames{at}aol.com
Financial Disclosure: The authors have indicated they have no financial relationships relevant to this article to disclose.
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ABSTRACT
THE USE OF BMIs...
