International Journal of
Environmental Researchand Public Health
Article
BMI,WaistCircumferenceReferenceValues
forChineseSchool-AgedChildrenandAdolescents
PeigeSong1,2,XueLi1,2,DanijelaGasevic2,AnaBorgesFlores3andZengliYu1,*
123
*
SchoolofPublicHealth,XinxiangMedicalUniversity,Xinxiang453003,China;peigesong@163.com(P.S.);xue.li@ed.ac.uk(X.L.)
CentreforPopulationHealthSciences,UniversityofEdinburgh,EdinburghEH89AG,UK;danijela.gasevic@ed.ac.uk
SchoolofPhilosophy,PsychologyandLanguageSciences,UniversityofEdinburgh,EdinburghEH89AD,UK;ablborges@gmail.com
Correspondence:yuzengli@outlook.com;Tel.:+86-371-6778-1929
AcademicEditor:PaulB.Tchounwou
Received:16March2016;Accepted:2June2016;Published:14June2016
Abstract:Background:Childhoodobesityhasbecomeoneofthemostseriouspublichealthchallengesinthe21stcenturyinmostdevelopingcountries.Thepercentilecurvetoolisusefulformonitoringandscreeningobesityatpopulationlevel,however,inChina,noof?cialrecommendationsonchildhoodbodymassindex(BMI)andwaistcircumference(WC)referencepercentileshavebeenmadeinpractice.Aims:toconstructthepercentilereferencevaluesforBMIandWC,andthentocalculatetheprevalenceofoverallandabdominalobesityforChinesechildrenandadolescents.Methods:Atotalof5062anthropometricrecordsforchildrenandadolescentsagedfrom7to18years(2679boysand2383girls)wereincludedforanalysis.Theparticipantswererecruitedaspartofthenationalrepresentative“ChinaHealthandNutritionSurvey”(CHNS).Age,gender,weight,height,andWCwereassessed.SmoothedBMIandWCpercentilecurvesandvaluesforthe3rd,5th,10th,15th,25th,50th,75th,85th,90th,95thand97thpercentileswereconstructedbyusingtheLambda-Mu-Sigma(LMS)method.Theprevalenceestimatesoftheoverallandabdominalobesitywerecalculatedbyusingthecut-offsfromourCHNSstudyandtheprevious“ChineseNationalSurveyonStudents’ConstitutionandHealth”(CNSSCH)study,respectively.ThedifferencebetweenprevalenceestimateswastestedbyaMcNemartest,andtheagreementbetweentheseprevalenceestimateswascalculatedbyusingtheCohen’skappacoef?cient.Results:Theprevalencevaluesofoverallobesitybasedonthecut-offsfromCHNSandCNSSCHstudieswereatanalmostperfectagreementlevelinboys(κ=0.93).However,amonggirls,theoverallobesityprevalencedifferedbetweenthestudies(p<0.001)andtheagreementwasweaker(κ=0.76).Theabdominalobesityprevalenceestimatesweresigni?cantdifferentaccordingtothetwosystemsbothinboysandgirls,althoughtheagreementreachedto0.88,whichrepresentedanalmostperfectagreementlevel.Conclusions:ThisstudyprovidednewBMIandWCpercentilecurvesandreferencevaluesforChinesechildrenandadolescentsaged7–18years,whichcanbeadoptedinfutureresearches.Largelongitudinalstudyisstillneededtorevealthechildhoodgrowthpatternandvalidatetheinconsistencebetweendifferentpercentilestudies.Keywords:BMI;waistcircumference;childhoodobesity;China
1.Introduction
Childhoodobesity,de?nedasanexcessivefataccumulationstatusinchildren[1,2],hasbecomeoneofthemostseriouspublichealthchallengesinthe21stcentury[3].Globally,approximately170millionchildren(agedlessthan18years)aresufferingfromthephysicalandpsychologicalconsequencescausedbyoverweightorobesity[4,5],whichmayresultindecreasedlifequalityInt.J.Environ.Res.PublicHealth2016,13,589;doi:10.3390/ijerph13060589
www.mdpi.com/journal/ijerph
Int.J.Environ.Res.PublicHealth2016,13,5892of13
andincreasedriskofdevelopingnon-communicablediseasessuchascardiovasculardisease,type2diabetesandcancersintheirlateradulthoodlife[6,7].Althoughtherearestillmanyregionsstrugglingwithchildhunger,suchasSouth-easternAsiaandSub-SaharanAfrica[8],thechildhoodobesityhasalreadyreachedendemicproportionsbyextendingtodevelopingcountries,includingChina[9,10].
Atthepopulationlevel,percentilecurveisausefultoolformonitoringandscreeningobesityamongschool-agedchildrenandadolescents[11].Formeasuringoverallobesity,themostcommonlyusedindicatorisBodyMassIndex(BMI)[12].Generally,overweightandobesityinchildrenarede?nedrespectivelybasedonthe85thpercentileand95thpercentileofBMIamongchildren[13].AlthoughBMIhasbeenusedtodemonstratetheweight-for-heightrelationshipandtosomeextentcanprovideanestimateofthebodyfatpercentage,BMIalonecannotre?ectthefatdistributionverycomprehensively,suchastheabdominalfatdeposits[14].
Abdominalobesity,whichisthedepositionofvisceralfat,isassociatedwithhigherriskofmetaboliccomplications,suchashyperlipidaemia,anddiabetes[15,16].Commonlyadoptedpredictiveindicatorsofabdominalobesityincludewaistcircumference(WC)andrelatedindicessuchasthewaist-to-heightandwaist-to-hipratios[16–18].WCisarelativelysimpleandconvenientmeasureandcanbereadilyusedtoestimatetheaccumulationofabdominalfat[19].Giventhatchildrenaregrowingandtheirbodiesaredevelopingovertheyears,auniformreferentvaluemaynotbeappropriate.Previousliteratessuggesttheuseofage-andgender-speci?cWCě90thpercentileasthethresholdforabdominalobesity[18,20,21].
InChina,noof?cialrecommendationsonchildhoodBMIandWCreferencepercentileshavebeenmadeinclinicalorpopulationpractice,however,basedondifferentinvestigations,severalreferencepercentileshavebeenestablishedatbothlocalandnationallevels[22–26].Amongthem,themostnationallyrepresentativeBMIandWCpercentilesweregeneratedbasedonalargecross-sectionalschool-basedstudyconductedin2005,namely,the“ChineseNationalSurveyonStudents’ConstitutionandHealth”(CNSSCH)[24,27],whichparticipantsincludedstudentsfromprimaryandhighschoolsaged7–18years[28].Themainlimitationofthestudywasthatthepercentileswereestablishedbasedononlycross-sectionaldata,thismaythereforelimitthere?ectionoftherealBMIandWCgrowthpatternwithage[24,27].Inaddition,thechildhoodgrowthpatternchangeswithtime,economicandsocialdevelopment,soitneedstoberegularlyupdated[29,30],thecurrentCNSSCHBMIandWCreferencepercentileswerebasedondataintheyearof2005,theusagemaybeimplausible.
Anotherprospectivehousehold-basedstudy“ChinaHealthandNutritionSurvey”(CHNS),whichhasbeenconductedsuccessivelyintheyearsof1989,1991,1993,1997,2000,2004,2006,2009and2011coveringnineprovinces(Guangxi,Guizhou,Heilongjiang,Henan,Hubei,Hunan,Jiangsu,LiaoningandShandong)withdifferentgeographies,economicdevelopmentlevels,andhealthindicators[31,32],hasboththemeritsofnationalrepresentativenessandlongitudinalfollow-upqualitywhichallowsbetterre?ectionofgrowthpattern[31].Tothebestofourknowledge,nopercentilecurvesforBMIandWChavebeenestablishedbasedonthedatafromCHNSforschool-agedchildrenandadolescents(7–18yearsold)inChina.Inaddition,althoughtheCNSSCHBMIandWCpercentileshavemadeinter-nationalcomparisonswiththepercentilesproposedbyWHOandtheUSCenterforDiseaseControlandPrevention,itisstillimperativetoaddressthepreviousstudylimitationsanddescribepercentilesbasedonanewnationaldatasetandthenconductanintra-nationalcomparison.
Inthisstudy,weaimtoconstructthepercentilereferencevaluesforBMIandWCbasedonCHNSdata,andthentocalculatetheprevalenceofoverallandabdominalobesitybyusingCHNSandCNSSCHcut-offsandmakeanintra-nationalcomparison.
Int.J.Environ.Res.PublicHealth2016,13,5893of13
2.MaterialsandMethods2.1.StudySample
DetailedinformationontheCHNSstudydesignhasbeenpublishedelsewhere[31].ThestudyprocedureswereapprovedbytheInstitutionalReviewBoardsoftheUniversityofNorthCarolina,ChapelHillandtheChineseCentreforDiseaseControl[33].Thisstudyisasecondarydataanalysisusingpublicandde-identi?eddatasetobtainedfromthemostrecentfourCHNS(2004,2006,2009and2011)toconstructthepercentilevalues,noethicsapprovalwasneeded[34].Atotalof3262school-agedparticipantswereincludedintheanalysis,amongthem,100(3.07%)participantshadthecompletefourfollow-upsfrom2004to2011,314(9.63%)werefollowedforthreetimes,872(26.73%)werefollowedfortwotimes,and1976(60.58%)wereonlyinvestigatedforonce,notalltheparticipantswereenrolledinthe?rstsurveyin2004,newparticipantsweregraduallyaddedinthefollowingsurveys,theaveragetimedmeasurementwas1.55foroneparticipant.Largesamplesizeisessentialforconstructingpercentilevaluesateachagegroup[35],soweincludedalltheanthropometricrecordsinthesefourCHNSandadoptedthemixedcross-sectional/longitudinalsample.Finally,atotalof5062anthropometricrecords(2679boysand2383girls)wereincludedandassessedforage,gender,weight,height,andWC.2.2.Anthropometry
Standardprocedureswerefollowedtoconductanthropometricmeasurementsbywell-trainedexaminers.Weightwasmeasuredtothenearest0.1kginlightclothingbyusingthecalibratedbeamscale.Heightwasmeasuredtothenearest0.1cmwithoutshoesbyusingaportablestadiometer,andWCwasmeasuredatamidpointbetweenthelowestribandtheiliaccrestinahorizontalplanebyusingnon-elastictape[33,36].Alldatacollectionstaffweretrainedinaninterobserverreliabilitytestingbeforesurveys[37].BMIwascalculatedasweight(kg)dividedbyheightsquared(m2).2.3.StatisticalAnalysis
Generalcharacteristicsofthechildrenandadolescentswerereportedasmean?SDorascountsandpercentages.Gender-speci?cpercentilevalueswerecalculatedandsmoothedbytheLambda-Mu-Sigma(LMS)methodwiththeLMSChartMakerProversion2.3software(TheInstituteofChildHealth,London,UK)[38],whichsummarizesachangingpercentileateveryagepointbasedonBox–Coxpowertransformationbythreesmoothedcurves:L(lambda,skewness),M(mu,median)andS(sigma,coef?cientofvariation).WepresentedthefollowingpercentilecurvesforBMIandWC:3rd,5th,10th,15th,25th,50th,75th,85th,90th,95thand97th.The5th,50thand95thpercentilesofBMI,andthe10th,50thand90thpercentilesofWCwereplottedtocomparebetweenboysandgirlsandwiththecorrespondingvaluesintheCNSSCHreferences.Overallobesitywasde?nedashavingage-andgender-speci?cBMIpercentileě95thandabdominalobesitywasde?nedashavingage-andgender-speci?cWCpercentileě90th.TheprevalenceofobesitywasdeterminedfortheCHNSstudysubjectsbyadoptingthecut-offsoftheCHNSandCNSSCHclassi?cationsystems,respectively,andMcNemartestwasusedtocomparethedifferencesinprevalence.TheagreementbetweentheseprevalencewastestedbytheCohen’skappacoef?cient(κ).Theagreementofκ<0.00indicates“poor”,0.00?κ?0.02“slight”,0.21?κ?0.40“fair”,0.41?κ?0.60“moderate”,0.61?κ?0.80“substantial”and0.81?κ?1.00“almostperfect”agreement[39–41].AllstatisticalanalyseswereconductedinIBMSPSSStatistics19.Statisticalsigni?cancewasconsideredatp<0.05andalltestsweretwo-sided.3.Results
ThedescriptivecharacteristicsoftheanthropometricrecordsareshowninTable1.Amongallthe5062recordsforschool-agedchildrenandadolescents,2679(52.9%)wereboysand2383(47.1%)weregirls.TheaverageBMIwere18.2?3.33kg/m2inboysand17.9?3.24kg/m2ingirls,theaverageWCwere64.9?10.89cminboysand62.2?9.42cmingirls.Figures1and2showthefullsetofsmoothedInt.J.Environ.Res.PublicHealth2016,13,5894of13
percentilecurvesofBMIandWCrespectivelyforChinesechildrenandadolescentsagedfrom7to18yearsaccordingtogender.Thecorresponding3rd,5th,10th,15th,25th,50th,75th,85th,90th,95thand97thpercentilevaluesforBMIandWCarepresentedinTables2and3.
Table1.Characteristicsoftheanthropometricrecords(n=5062,mean(SD)).
AgeBoys(n=2679)2)2n(%)BMI(kg/mn(%) BMI (kg/m)Girls(n=2383)WCnn(%)WC(cm)BMI(kg/m22) WC )WC (cm)(cm)(%)BMI (kg/m(cm)54.1 (7.33) 203 (8.52) 16.0 (3.71) 52.9 (6.30) 2) WC 54.1(7.33)20316.0(3.71)52.9(6.30)WC (cm)n(8.52)(%)BMI (kg/m(cm)57.0 (7.96) 203 (8.52) 16.1 (2.93) 54.9 (6.76) 57.0(7.96)203(8.52)16.1(2.93)54.9(6.76)54.1 (7.33) 203 (8.52) 16.0 (3.71) 52.9 (6.30) 58.4(7.55)241(10.11)16.3(3.11)56.1(7.22)58.4 (7.55) 241 (10.11) 16.3 (3.11) 56.1 (7.22) 57.0 (7.96) 203 (8.52) 16.1 (2.93) 54.9 (6.76) 60.9(8.57)219(9.19)16.5(2.85)57.9(7.62)60.9 (8.57) 219 (9.19) 16.5 (2.85) 57.9 (7.62) 58.4 (7.55) 241 (10.11) 16.3 (3.11) 56.1 (7.22) 63.8(9.29)239(10.03)17.2(2.98)60.8(8.17)63.8 (9.29) 239 (10.03) 17.2 (2.98) 60.8 (8.17) 60.9 (8.57) 219 (9.19) 16.5 (2.85) 57.9 (7.62) 64.2(8.92)231(9.69)17.7(3.00)63.1(8.46)64.2 (8.92) 231 (9.69) 17.7 (3.00) 63.1 (8.46) 63.8 (9.29) 239 (10.03) 17.2 (2.98) 60.8 (8.17) 66.9(8.82)211(8.85)18.4(2.58)65.4(7.05)66.9 (8.82) 211 (8.85) 18.4 (2.58) 65.4 (7.05) 69.7(9.09)274(11.50)19.1(2.66)67.3(8.10)64.2 (8.92) 231 (9.69) 17.7 (3.00) 63.1 (8.46) 69.7 (9.09) 274 (11.50) 19.1 (2.66) 67.3 (8.10) 71.9(10.25)186(7.81)19.6(2.70)68.3(7.97)66.9 (8.82) 211 (8.85) 18.4 (2.58) 65.4 (7.05) 71.9 (10.25) 186 (7.81) 19.6 (2.70) 68.3 (7.97) 73.3(8.34)176(7.39)19.9(2.25)68.7(6.88)69.7 (9.09) 274 (11.50) 19.1 (2.66) 67.3 (8.10) 74.6(8.88)132(5.54)20.2(2.76)69.6(7.49)73.3 (8.34) 176 (7.39) 19.9 (2.25) 68.7 (6.88) 71.9 (10.25) 186 (7.81) 19.6 (2.70) 68.3 (7.97) 74.2(9.42)68(2.85)20.0(2.35)69.8(7.96)74.6 (8.88) 132 (5.54) 20.2 (2.76) 69.6 (7.49) 73.3 (8.34) 176 (7.39) 19.9 (2.25) 68.7 (6.88) 64.9(10.89)2383(100.00)17.9(3.24)62.2(9.42)74.2 (9.42) 68 (2.85) 20.0 (2.35) 69.8 (7.96) 74.6 (8.88) 132 (5.54) 20.2 (2.76) 69.6 (7.49) 64.9 (10.89) 17.9 (3.24) 62.2 (9.42) 74.2 (9.42) 2383 (100.00) 68 (2.85) 20.0 (2.35) 69.8 (7.96) 64.9 (10.89) 2383 (100.00) 17.9 (3.24) 62.2 (9.42) 7 (7.0–7.9) 261(9.74)261 (9.74) 15.8 (2.44) 7(7.0–7.9)15.8(2.44)n(%) BMI (kg/m2)8 (8.0–8.9) 223261 (9.74) 223 (8.32) 16.416.4 (3.00) 8(8.0–8.9)(8.32)(3.00)7 (7.0–7.9) 15.8 (2.44) 9(9.0–9.9)(8.81)(3.30)9 (9.0–9.9) 236223 (8.32) 236 (8.81) 16.816.8 (3.30) 8 (8.0–8.9) 16.4 (3.00) 10(10.0–10.9)257(9.59)17.2(3.15)10 (10.0–10.9) 257 (9.59) 17.2 (3.15) 9 (9.0–9.9) 236 (8.81) 16.8 (3.30) 11(11.0–11.9)18.0(3.36)11 (11.0–11.9) 278(10.38)278 (10.38) 18.0 (3.36) 10 (10.0–10.9) 257 (9.59) 17.2 (3.15) 12(12.0–12.9)235(8.77)17.9(2.89)
12 (12.0–12.9) 235 (8.77) 17.9 (2.89) 11 (11.0–11.9) 18.0 (3.36) 13(13.0–13.9)243278 (10.38) (9.07)18.8(3.24)13 (13.0–13.9) 243 (9.07) 18.8 (3.24) 14(14.0–14.9)(8.62)19.1(2.96)12 (12.0–12.9) 231235 (8.77) 17.9 (2.89) 14 (14.0–14.9) 231 (8.62) 19.1 (2.96) 15(15.0–15.9)227(8.47)19.8(3.14)13 (13.0–13.9) 243 (9.07) 18.8 (3.24) 15 (15.0–15.9) 212231 (8.62) 227 (8.47) 19.919.8 (3.14) 16(16.0–16.9)(7.91)(2.62)14 (14.0–14.9) 19.1 (2.96) 17(17.0–17.9)(6.76)(2.63)16 (16.0–16.9) 181227 (8.47) 212 (7.91) 20.419.9 (2.62) 15 (15.0–15.9) 19.8 (3.14) 18(18.0–18.9)95(3.55)20.3(2.98)17 (17.0–17.9) 181 (6.76) 20.4 (2.63) 16 (16.0–16.9) 212 (7.91) 19.9 (2.62) Total(7.0–18.9)2679(100.00)18.2(3.33)18 (18.0–18.9) 95 (3.55) 20.3 (2.98) 17 (17.0–17.9) 181 (6.76) 20.4 (2.63) Total (7.0–18.9) 18.2 (3.33) 18 (18.0–18.9) 2679 (100.00) 95 (3.55) 20.3 (2.98) Total (7.0–18.9) 2679 (100.00) 18.2 (3.33) Figure 1. Gender- and age- specific BMI percentile curves for Chinese children and adolescents aged Figure1.Gender-andage-speci?cBMIpercentilecurvesforChinesechildrenandadolescentsaged7–18 years. Figure 1. Gender- and age- specific BMI percentile curves for Chinese children and adolescents aged 7–18years.
7–18 years. Figure 2. Gender- and age- specific WC percentile curves for Chinese children and adolescents aged 7–18 years. Figure 2. Gender- and age- specific WC percentile curves for Chinese children and adolescents aged Figure2.Gender-andage-speci?cWCpercentilecurvesforChinesechildrenandadolescentsaged7–18 years. 7–18years.
Int.J.Environ.Res.PublicHealth2016,13,5895of13
Table2.Gender-andAge-speci?cBMIpercentilevaluesforChinesechildrenandadolescentsaged7–18years(n=5062).
Age789101112131415161718
PercentilesforBoys
3rd12.612.712.913.213.614.014.515.015.616.016.316.2
5th12.913.013.213.513.914.314.815.415.916.416.616.6
10th13.413.513.714.114.514.915.416.016.516.917.217.2
15th13.713.914.114.514.915.315.816.416.917.417.717.6
25th14.214.514.815.115.616.016.517.117.618.118.318.3
50th15.415.816.216.717.117.618.118.619.219.619.919.9
75th16.917.518.118.719.219.620.120.621.121.521.821.9
85th17.918.719.420.020.621.021.522.022.422.723.023.2
90th18.719.620.421.221.722.122.623.023.423.724.024.2
95th20.021.222.323.123.824.124.524.925.225.425.725.9
97th21.022.523.824.825.425.726.126.326.526.726.927.2
3rd12.112.312.512.813.313.914.615.315.816.216.316.3
5th12.412.612.813.113.614.214.915.616.116.616.716.7
10th12.913.113.313.614.114.715.516.116.717.117.217.2
15th13.213.513.714.014.515.115.916.517.117.517.617.6
PercentilesforGirls25th13.814.114.314.615.115.816.517.217.718.218.318.3
50th15.215.515.716.016.617.217.918.619.119.619.719.7
75th17.017.317.517.818.419.019.820.420.921.321.521.5
85th18.318.618.819.119.720.321.021.622.122.422.622.7
90th19.319.619.820.120.721.321.922.523.023.323.523.6
95th21.221.421.621.922.423.023.624.124.524.825.025.1
97th22.722.923.123.323.824.424.925.325.725.926.126.2
Table3.Gender-andAge-speci?cWCpercentilevaluesforChinesechildrenandadolescentsaged7–18years(n=5062).
Age789101112131415161718
PercentilesforBoys
3rd41.143.245.247.249.150.752.754.957.058.759.860.4
5th42.344.546.548.550.452.154.156.458.560.261.361.8
10th44.446.648.650.752.754.456.458.760.962.663.764.2
15th45.848.150.152.354.356.058.060.462.564.365.365.8
25th48.250.552.654.856.858.560.663.065.267.068.068.4
50th53.155.557.760.062.163.966.068.570.772.573.573.8
75th58.961.563.866.268.470.272.474.977.278.979.880.0
85th62.665.267.570.072.274.076.278.881.182.883.683.7
90th65.267.970.372.775.076.879.081.683.985.686.486.4
95th69.672.474.877.279.581.383.586.188.490.190.890.6
97th72.775.577.980.482.784.586.789.391.693.293.893.6
3rd40.542.243.845.848.150.552.854.656.057.057.758.3
5th41.943.645.247.149.451.854.155.957.258.158.859.4
10th44.245.847.449.251.553.956.257.959.260.160.761.2
15th45.847.448.950.753.055.457.659.460.661.462.062.4
PercentilesforGirls25th48.149.751.253.055.357.759.961.762.863.664.164.5
50th52.754.355.857.659.962.464.766.467.568.268.668.8
75th57.559.260.762.765.167.770.171.872.973.573.974.0
85th60.261.963.665.668.170.873.375.176.276.877.177.2
90th62.063.865.567.670.273.075.677.478.679.379.679.7
95th64.866.768.570.773.576.579.281.282.583.283.583.6
97th66.668.670.572.975.878.981.883.985.286.086.486.5
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