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Journal of the American College of Nutrition, Vol. 25, No. 5, 403-408 (2006)
Published by the American College of Nutrition

Screening Performances of the International Obesity Task Force Body Mass Index Cut-Off Values in Adolescents

Luis A. Moreno, MD, PhD, María G. Blay, MD, Gerardo Rodríguez, MD, PhD, Vicente A. Blay, MD, PhD, María I. Mesana, MD, José L. Olivares, MD, PhD, Jesús Fleta, MD, PhD, Antonio Sarría, MD, PhD, Manuel Bueno, MD, PhD and AVENA-Zaragoza Study Group

Department of Pediatrics, University School of Health Sciences, University of Zaragoza (L.A.M., G.R., M.I.M., J.L.O., J.F., A.S., M.B.)
Endocrinology Unit, Military Hospital of Zaragoza (M.G.B., V.A.B.), Zaragoza, SPAIN

Address reprint requests to: Luis A. Moreno, MD, PhD, E.U. Ciencias de la Salud, Universidad de Zaragoza, Domingo Miral s/n, 50009 Zaragoza, SPAIN. E-mail: lmoreno{at}unizar.es


   ABSTRACT
TOP
 FOOTNOTES
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 CONCLUSIONS
 ACKNOWLEDGMENTS
 REFERENCES
 
Objective: To try to improve the International Obesity Task Force (IOTF) BMI cut-off values, in terms of prediction of body fat percentage assessed by dual-energy X-ray absorptiometry (DXA), in adolescents.

Methods: Cross-sectional survey of the adolescents from the city of Zaragoza (Spain). For this analysis we have included 286 adolescents (116 boys and 170 girls) aged 13.0–17.9 years. Body mass index (BMI) was calculated as body weight (kg), divided by height (m) squared. The percentage of body fat (BF%) was estimated by the use of DXA.

Results: We have calculated, new BMI cut-off values (AVENA cut-offs) to predict BF%, for boys and girls in each age group. In male adolescents, sensitivity was higher with the IOTF cut-offs (0.71, 95th C.I.: 0.44, 0.90) than with the AVENA ones (0.53, 95th C.I.: 0.28, 0.77), and specificity was very similar with both cut-off values (0.86 and 0.88, respectively), the differences being not statistically significant. In girls, both sensitivities (0.75 and 0.79, respectively) and specificities (0.90 and 0.92, respectively) were very similar with both cut-off values, and the differences, not significant.

Conclusions: Optimization of the IOTF BMI cut-off values, in terms of BF%, seems not to be possible in adolescents. The IOTF criteria should be used only for overweight and obesity screening; however, in clinical settings, a more accurate measure of body fat should be recommended.

Key words: adolescence, body composition, diagnostic tests, reference method


   INTRODUCTION
TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 CONCLUSIONS
 ACKNOWLEDGMENTS
 REFERENCES
 
International Obesity Task Force (IOTF) body mass index (BMI) cut-off values for the diagnosis of overweight and obesity in children and adolescents are widely accepted, but they have some limitations. BMI is commonly used in clinical practice because it is straightforward and relatively cheap to obtain, but its clinical interpretation remains controversial. Other techniques, generally confined in use to research studies, such as underwater weighing and dual energy-x-ray absorptiometry (DXA), offer accurate measurement of adiposity, but are deemed unsuitable for routine clinical use because they are relatively expensive, rely on more complex technologies, and are technically more demanding.

In the recent years, there are a certain number of studies that have described the relationship between BMI and % total body fat content, measured with a reference method (underwater weighing or DXA), in children and adolescents [1–7]. In general, correlations were higher in females than in males, and also were higher in prepubertal children than in those during the pubertal development. Correlations were almost in all the cases lower than 0.90, and in some age and gender groups, close to 0.60.

Maynard et al. [7], in the Fels Longitudinal Study, have also observed that, in each sex, annual increases in BMI were driven primarily by increases in FFM/stature2 until late adolescence, with increases in TBF/stature2 contributing to a larger proportion of the BMI increases in girls than in boys. Therefore, we can consider that annual changes in BMI during childhood are generally attributed to the lean rather than to the fat component of BMI.

Studies using BMI to identify children with excess adiposity have shown good performances for this anthropometric index. Sardinha et al. [8] have observed that, in male children aged 10 to 15 years, the areas under ROC curves for BMI ranged from 0.89 to 0.95 in boys and from 0.61 to 0.97 in girls. Sarriá et al. [9] have also observed that, in children aged 7 to 16 years, the area under the ROC curve for age-adjusted BMI was 0.86. No information exists about the screening performance of the IOTF reference standards in children or adolescents. Therefore, the aim of our study was to try to improve the IOTF cut-off values, in terms of prediction of body fat percentage assessed by dual-energy X-ray absorptiometry (DXA) in adolescents.


   MATERIALS AND METHODS
TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 CONCLUSIONS
 ACKNOWLEDGMENTS
 REFERENCES
 
Subjects
The AVENA (Alimentación y Valoración del Estado Nutricional en Adolescentes) Study is a multicenter cross-sectional survey. The AVENA study was designed to evaluate the nutritional status, dietary and leisure time habits, and physical activity and fitness of a representative sample of Spanish adolescents, in order to identify risk factors for chronic diseases in adulthood. The overall methodology of this study has been previously described [10]. In order to have a representative sample of Spanish adolescents, we have selected adolescents from five Spanish cities (Santander, Granada, Murcia, Zaragoza and Madrid). The sample size was calculated in order to describe the variable with the highest variability. We have checked all the variables included in the study, and we have chosen the BMI, because it’s very high variability. The established statistical error was +/– 0.3. In the city of Zaragoza we have studied 348 adolescents aged 13.0 to 17.9 years (146 boys and 198 girls), from 19 school groups in 14 public and private schools that represent the socio-economic distribution of the population in this area. Fifteen school groups from 11 public and private schools accepted to go the Military Hospital of Zaragoza in order to measure body composition by DXA. For this analysis we have included 286 adolescents (116 boys and 170 girls) aged 13.0–17.9 years, which accepted to go to the Hospital for the DXA measurement. After receiving complete information about the aims and methods of the study, all the included subjects and/or their parents or guardians signed fully informed written consent. The protocol was approved by the Review Committee for Research Involving Human Subjects of the Hospital Universitario Marqués de Valdecilla (Santander, Spain).

Socio-economic status was assessed by means of the education level and occupation of the father, as previously described [11]. Pubertal status was investigated according with the method described by Tanner [12].

Body Composition Analysis
Body mass index (BMI) was calculated as body weight (kg) without shoes and with light clothing, divided by height (m) squared. Body weight was measured to 0.05 kg using a standard beam balance. Height was measured to the nearest 1 mm using a stadiometer incorporated to the scale. The anthropometric material was calibrated every day. The International Obesity Task Force (IOTF) body mass index (BMI) cut-off values were used for the diagnosis of overweight and obesity in children and adolescents [13].

The percentage of body fat (BF%) was estimated by the use of DXA (Lunar DPX-L scanner; Lunar Corporation, Madison, WI), and DPX-L software (Lunar Corporation) was used to analyse the DXA scans. The paediatric medium scan mode was used from 13 to 16 y, and the adult software in adolescents older than 16 y. The scanner determines total fat mass, bone-free lean tissue mass, bone mineral content (in g), and areal bone mineral density (in g/cm2). BF% determined by DXA is calculated as [fat mass/(fat mass + bone-free lean tissue mass + bone mineral content) x 100]. All DXA scans were completed on the same scanner and software and by the same person who had been fully trained in the operation of the scanner, the positioning of subjects, and the analysis of results according to manufacturer’s guidelines.

Statistical Analysis
Statistical analyses were performed with SPSS 11.5 software, and results are presented as mean and standard deviation. In order to try to improve the IOTF cut-off values, we have calculated, in each age and sex group (13.0–13.9, 14.0–14.9, 15.0–15.9, 16.0–16.9, and 17.0–17.9), regression equations with BMI as the dependent variable and BF% as the independent variable. With those equations, we have calculated the BMI values corresponding to the 85th percentile of the BF% distribution in each age and sex group (AVENA cut-offs). We have compared the AVENA cut-off values with the IOTF ones, in terms of sensitivity (the true-positive rate) and specificity (the true-negative rate) for the detection of excess BF% (>85th percentile). 95th confidence intervals for sensitivity and specificity were calculated for an exact binomial distribution.


   RESULTS
TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
CONCLUSIONS
 ACKNOWLEDGMENTS
 REFERENCES
 
The main characteristics of both boys and girls are presented in Tables 1 and 2, respectively. In males, the socio-economic status distribution was: low status 7.1%, medium-low 31.3%, medium 42.4%, medium-high 16.2% and high 3.0%; in females, the socioeconomic status was 6.4% low, 30.5% medium-low, 39.7% medium, 19.1% medium-high and 4.3% high. In males, 19% were in Tanner stage 2–3, 42.2% in stage 4, and 38.8% in stage 5; in females, the Tanner stage distribution was 3.0% in stage 2–3, 45.6% in stage 4 and 51.5% in stage 5. The percentage of overweight adolescents (excluding obese ones) was 18.8% in males and 18.2 in females, and the proportion of obese adolescents was 4.5% in males and 1.3% in females. Body fat percentage decreased with Tanner stage in boys (2–3: 22.52 ± 12.70, 4: 18.11 ± 11.57, and 5: 15.72 ± 7.93), and increased in girls (2–3: 19.72 ± 2.04, 4: 25.11 ± 7.44, and 5: 28.72 ± 7.25).


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  		Table 1. Characteristics of the Study Population in Males, by Age Group

 

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  		Table 2. Characteristics of the Study Population in Females, by Age Group

 
Regression equations for BMI from body fat percentage both in boys and in girls are presented in Tables 3 and 4, respectively. In boys, the models explained from 11.8 to 75.0% of the variability of BMI, and in girls from 49.4 to 74.2%. The calculated, new cut-off values (AVENA cut-offs), for boys and girls are also presented in Tables 3 and 4, respectively (predicted BMI).


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  		Table 3. Regression Equations for Body Mass Index from Body Fat Percentage and Predicted 85th Percentile BMI Cut-Off Values, in Male Adolescents

 

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  		Table 4. Regression Equations for Body Mass Index from Body Fat Percentage and Predicted 85th Percentile BMI Cut-Off Values, In Female Adolescents

 
In male adolescents (Table 5), sensitivity was higher with the IOTF cut-offs than with the AVENA ones, and specificity was very similar with both cut-off values, the differences being not statistically significant. In girls (Table 6), both sensitivity and specificity were very similar with both cut-off values, and the differences, again, not significant. In both gender, specificities were higher than sensitivities, with both cut-off values.


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  		Table 5. Sensitivity and Specificity of AVENA and IOTF BMI Cut-Off Values for the Screening of Overweight Male Adolescents

 

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  		Table 6. Sensitivity and Specificity of AVENA and IOTF BMI Cut-Off Values for the Screening of Overweight Female Adolescents

 

   DISCUSSION
 
Childhood obesity has increased at alarming rates in the last decades, not only in the US [14,15], but also in Europe [16,17]. The recent identification of major abnormalities of carbohydrate metabolism in obese children and adolescents, underscore the importance of childhood obesity as a major public health priority [18,19]. International Obesity Task Force (IOTF) body mass index (BMI) cut-off values for the diagnosis of overweight and obesity in children and adolescents [13] are widely accepted, but they have some limitations, concerning mainly the populations used to establish this new definition. That is the reason why we have tried to optimise those values from the results of the AVENA-Zaragoza study.

There is no widely accepted definition of excess body fat for adolescents. The choice of a reference point to define overweight or obesity by BF% is subjective in that universally accepted figures do not exist. No reference ranges derived from random population sample measurements of adiposity are available. That is the reason why we have defined overweight or excess adiposity status as BF% at or above the age-adjusted 85th percentile. This criterion was chosen to ensure adequate numbers for statistical analysis because, in clinical terms, the 85th percentile seems a reasonable choice for excess adiposity, and to compare the results with those of other authors [8,9].

A variety of measures are available to clinicians and researchers for the assessment of adiposity in children. BMI is commonly used in clinical practice because it is straightforward and relatively cheap to obtain, but its clinical interpretation remains controversial. Mei et al. [20] have compared the performance of BMI-for-age with that of Rohrer index-for-age, and have observed that the performance was better for BMI than for Rohrer index in predicting under- and overweight assessed by DXA, in children and adolescents aged 2–19 years. Taylor et al. [21] have also showed that BF% values associated with BMI classifications of overweight and obesity vary considerably with age in growing children, particularly in girls.

To determine the IOTF cut-off values, Cole et al. [13] listed the BMI values for each half-year of age from 2 to 18 years, which correspond to the adult BMI cut-offs of 25 and 30 kg/m2. These cut-offs were created with the use of an international database of >190000 subjects aged 0–25 years from 6 countries. Sex-specific BMI centile curves were constructed by the use of the LMS method [22]. The percentiles corresponding to BMI cut-offs of 25 and 30 kg/m2 at the age of 18 years were used to denote overweight and obesity at all ages (2–18 years).

In our study we assessed the validity of our own cut-off values for BMI and, a priori, they should be the best ones in our own population. The new reference values, AVENA cut-offs, ranged from 22.72 to 27.96 in boys, and from 22.52 to 25.54 in girls. With these new values, we could attend better screening performances, at least in our own study; however, screening performances with IOTF and AVENA cut-offs were very similar; therefore, we think that in terms of BF%, it is not possible to improve the screening performances of the IOTF reference standards. In both genders, specificities were higher than sensitivities; therefore the ability to detect non-overweight children was higher than the ability of the test to identify overweight children.

In boys, Sarría et al. [9] have observed that for the screening of excess adiposity (BF% assessed by underwater weighing > 85th percentile) sensitivity at the best cut-off value (70th percentile) was 0.81 and specificity 0.79; the 85th BMI percentile showed a sensitivity of 0.50 and a specificity of 0.91. These last results are very similar to those observed with the AVENA cut-offs.

Very recently, Katzmarzyk et al. [23] have observed that overweight children participating in the Québec Family Study, defined in terms of IOTF reference cut-offs, had between 1.6 and 9.1 times the risk of elevated cardiovascular risk factors, compared to normal-weight participants. Further, boys and girls with four or more risk factors were 19 and 43 times more likely to be overweight, respectively, compared to participants with no risk factors. These results support that the IOTF cut-offs are related to health risks in youth.

The adolescents included in our study showed a similar socio-economic status, Tanner stages and overweight and obesity proportions distributions when compared with the general Spanish adolescent population [11,24]. Changes in body composition during adolescence according with age and Tanner stage in our study are similar to those described in different preliminary papers as typical of the adolescent period [4,25].

The strengths of our study include being a representative sample of adolescents of a limited age group and the use of DXA, a validated measure of BF% in animal and human studies [26–29]. Wang et al. [30] compared 16 currently used total body fat methods to a 6-compartment criterion model based on in vivo neutron activation analysis. Although all 16 methods were highly correlated with the 6-compartment criterion model, 3 groups emerged based on their comparative characteristics. The best agreements were found with multicompartment model methods, followed by other methods including DXA, that slightly underestimates body fat.

One limitation of the study could be the small number of subjects in the 17.0–17.9 y group, in males. However, if we excluded from the analysis this age group, the results were very similar. The reason for this short subject’s number in this category was the non-participation of some schools selected for the complete AVENA-Zaragoza study.


   CONCLUSIONS
TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 CONCLUSIONS
ACKNOWLEDGMENTS
 REFERENCES
 
Body mass index by itself appears to be useful as an approximate classification of obesity status; it cannot accurately predict a specific individual’s percentage body fat. Therefore, BMI could be used as a screening test, but in clinical practice it would be indicated to assess the % of total body fat using a more accurate method, like DXA. Optimization of the IOTF BMI cut-off values, in terms of BF%, seems not to be possible in adolescents. The IOTF criteria should be used only for overweight and obesity screening; however, in clinical settings, a more accurate measure of body fat should be recommended.


   ACKNOWLEDGMENTS
TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 CONCLUSIONS
 ACKNOWLEDGMENTS
REFERENCES
 
This study has been supported by Instituto de Salud Carlos III (Spain): Grant FIS 00/0015-05 and Red de Centros RCESP, C03/09.


   FOOTNOTES
TOP
 FOOTNOTES
ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 CONCLUSIONS
 ACKNOWLEDGMENTS
 REFERENCES
 
AVENA-Zaragoza Study Group: M Bueno, LA Moreno, A Sarría, J Fleta, G Rodríguez, CM Gil, MI Mesana, Y Loya, JA Casajús, MG Blay, VA Blay.

Received January 26, 2005. Accepted July 26, 2006.


   REFERENCES
TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 CONCLUSIONS
 ACKNOWLEDGMENTS
 REFERENCES
 

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