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The Validity of BMI As an Indicator of Body Fatness and Risk Among Children

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The Validity of BMI As an Indicator of Body Fatness and Risk Among Children SUPPLEMENT ARTICLE The Validity of BMI as an Indicator of Body Fatness and Risk Among Children CONTRIBUTORS: David S. Freedman, PhD and Bettylou Sherry, PhD abstract Division of Nutrition, Physical Activity, and Obesity, Centers for PURPOSE OF REVIEW: Although the prevalence of childhood obesity, as Disease Control and Prevention, Atlanta, Georgia assessed by BMI (kg/m2), has tripled over the last 3 decades, this index KEY WORDS is a measure of excess weight rather than excess body fatness. In this BMI, obesity, children, body fatness, DEXA, racial differences, risk factors, skinfolds, waist circumference review we focus on the relation of BMI to body fatness and health risks, Ն ABBREVIATIONS particularly on the ability of BMI for age 95th Centers for Disease CDC—Centers for Disease Control and Prevention Control and Prevention [CDC] percentile to identify children who have DEXA—dual-energy radiograph absorptiometry excess body fatness. We also examine whether these associations dif- FMI—fat mass index FFMI—fat-free mass index fer according to race/ethnicity and whether skinfold and circumfer- IOTF—International Obesity Taskforce ence measurements provide additional information on body fatness or AUC—area under the receiver operator characteristic curve health risks. WHtR—waist-to-height ratio RESULTS: The accuracy of BMI varies according to the degree of body www.pediatrics.org/cgi/doi/10.1542/peds.2008-3586E fatness. Among relatively fat children, BMI is a good indicator of excess doi:10.1542/peds.2008-3586E adiposity, but differences in the BMIs of relatively thin children can be Accepted for publication Apr 29, 2009 largely due to fat-free mass. Although the accuracy of BMI in identifying Address correspondence to David S. Freedman, PhD, Centers for children with excess body fatness depends on the chosen cut points, Disease Control and Prevention, 4770 Buford Hwy, Mailstop K-26, Atlanta, GA 30341-3717. E-mail: [email protected] we have found that a high BMI-for-age has a moderately high (70%– PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). 80%) sensitivity and positive predictive value, along with a high speci- ficity (95%). Children with a high BMI are much more likely to have Copyright © 2009 by the American Academy of Pediatrics adverse risk factor levels and to become obese adults than are thinner FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. children. Skinfold thicknesses and the waist circumference may be useful in identifying children with moderately elevated levels of BMI (85th to 94th percentiles) who truly have excess body fatness or ad- verse risk factor levels. CONCLUSION: A BMI for age at Ն95th percentile of the CDC reference population is a moderately sensitive and a specific indicator of excess adiposity among children. Pediatrics 2009;124:S23–S34 PEDIATRICS Volume 124, Supplement 1, September 2009 S23 Downloaded from www.aappublications.org/news by guest on October 1, 2021 Although BMI (kg/m2) is widely used as prefer this terminology,5 it can create children who are classified as having an index of body fatness, it is a mea- confusion between high levels of BMI excess body fatness; this, in turn, sure of weight relative to height rather and high levels of body fatness. Be- would influence the ability of a high than of adiposity. BMI cannot distin- cause a main goal of this review is to BMI to correctly identify children with guish between body fatness, muscle quantify the ability of a high BMI (ex- excess fatness (positive predictive mass, and skeletal mass, and its use cess weight) to identify children who value). In addition, random errors in can result in large errors in the esti- have a high level of body fatness, we DEXA-estimated body fatness would re- mation of body fatness.1 The weight specify the BMI cut points (eg, BMI for duce the (apparent) screening perfor- and height changes that occur during age Ն95th CDC percentile) that are mance of BMI. growth (ages 5–18 years) result in used to classify overweight and obese Body fatness is usually standardized substantial (ϳ50%) increases in BMI, children in addition to the descriptive for body weight and expressed as per- further complicating the interpreta- terms. A high level of body fatness is cent body fat [fat mass (kg)/body tion of this index among children and termed “excess body fatness.” weight (kg)], but an alternative is to adolescents. For example, increases in express fat mass relative to height the BMI levels of boys during adoles- CHILDHOOD BMI AND BODY squared. This leads to the use of fat cence seem to be largely the result of FATNESS mass index (FMI) (fat mass/height increases in fat-free mass rather than Measurement of Body Fatness squared) and the fat-free mass index body fatness.2 Although an ideal measure of body fat- (FFMI) (fat-free mass/height squared).11,12 BMI has been characterized as being ness would be accurate, precise, and Because FMI ϩ FFMI ϭ BMI, the use of “almost useless as an estimator of accessible, with widely available popu- these indices allows one to easily as- percentage of body fat in normal- lation data, no existing measure satis- sess whether BMI differences (be- 3 weight children,” but much evidence 7 fies all these criteria. Reference meth- tween subjects, ages, or time periods) indicates that a child with a high BMI ods are expensive and can be are a result of fat or fat-free mass. relative to his or her gender and age inaccessible, and the simpler, widely Although excess body fatness among peers (BMI for age) is likely to have used anthropometric methods can children would ideally be defined on excess body fatness. In this review we be inaccurate.3 The 4-compartment the basis of disease risk, this may be focus on the relation of childhood BMI model, which incorporates indepen- difficult. Almost all studies of health to body fatness and health risks, par- dent estimates of mineral, total body outcomes have examined the effects of ticularly on the ability of a high BMI water, body density, and body weight, level to correctly identify a child with is widely viewed as the most accurate excess weight rather than body fat- excess body fatness. In addition, we ex- method for calculating body fatness,8 ness, and longitudinal studies span- amine whether these associations dif- but it is time consuming, expensive, ning many decades would be neces- fer according to race/ethnicity and and available at few locations. sary to have childhood body-fatness cut points to be based on associations whether skinfold and circumference Although the initial costs are high, the with clinical outcomes. Furthermore, measurements provide additional in- speed and low operating costs of dual- because the relation of childhood body formation on body fatness or health energy radiograph absorptiometry risks. (DEXA) has led to its use as a refer- fatness to disease outcomes is likely to The term “obesity” is frequently used ence method in many studies that be influenced by adult levels of body to refer to a high BMI among adults have examined the screening ability of fatness, it would be necessary to have and children,4,5 and the adult cut point BMI. These estimates of fat mass are multiple measurements of body fat- for obesity (BMI Ն 30 kg/m2) is approx- highly correlated with those from 4- ness throughout life. Even among imately the 95th percentile of BMI for compartment models, but can be influ- adults, a World Health Organization ex- age among 19-year-old boys and 17- enced by several factors including the pert committee concluded that “there year-old girls in the Centers for Dis- hydration of the subjects and the is no agreement about cutoff points ease Control and Prevention (CDC) equipment manufacturer, which cre- for the percentage of body fat that reference population6 (an SAS pro- ates the potential for systematic bi- constitutes obesity.”13 The derivation gram for the CDC growth charts is ases and large errors for a single and use of various cut points for ex- available at www.cdc.gov/nccdphp/ subject.3,8–10 A bias would not influ- cess body fatness are discussed be- dnpa/growthcharts/resources/sas.htm). ence the relative ranking of subjects, low in “Classification of Excess Body Although there are several reasons to but it could influence the proportion of Fatness.” S24 FREEDMAN and SHERRY Downloaded from www.aappublications.org/news by guest on October 1, 2021 SUPPLEMENT ARTICLE Anthropometry eases, the large increases in BMI that percentile of this reference population Anthropometry is a widely used, inex- occur during growth and development as obese, and children with BMI levels pensive method for assessing body fat- require a “high” BMI to be defined rel- between the 85th and 94th percentiles ness, but it can be inaccurate. The ative to other children of the same gen- as overweight. (These 2 BMI-for-age most frequent measurements are der and age. (Because body fatness categories had originally been termed weight and height, and these are usu- also changes substantially with age, “overweight” and “at risk for over- ally combined as weight/heightp; the “excess body fatness” is also typically weight.”23,24) Older adolescents with a power “p” can be chosen to minimize defined relative to a child’s peers.) BMI at Ն25 kg/m2 (ϳ85th percentile at the correlation with height or to maxi- The use of a reference population to ages 16–17 years in the reference pop- mize the correlation with body fatness. classify gender- and age-specific lev- ulation) are also considered to be BMI is a power index with p ϭ 2.
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