Diagnostic performance of body mass index to identify obesity as defined by body adiposity in children and adolescents: a systematic review and meta-analysis

Problems with the Fraser report Chapter 1: Pitfalls in BMI time trend analysis

The first chapter of the Fraser report "Obesity in Canada: Overstated Problems, Misguided Policy Solutions" presents a flawed and misleading analysis of BMI time trends. The objective of this commentary is to provide a tutorial on BMI time trend analysis through the examination of these flaws. Three issues are discussed: 1. Spotting regions of confidence interval overlap is a statistically flawed method of assessing trend; regression methods which measure the behaviour of the data as a whole are preferred. 2. Temporal stability in overweight (25≤BMI<30) prevalence must be interpreted in the context of the underlying population BMI distribution. 3. BMI is considered reliable for tracking population-level weight trends due to its high correlation with body fat percentage. BMI-defined obesity prevalence represents a conservative underestimate of the population at risk. The findings of the Fraser report Chapter 1 are either refuted or substantially mitigated once the above issues are accounted for, and we do not find that the 'Canadian situation largely lacks a disconcerting or negative trend', as claimed. It is hoped that this commentary will help guide public health professionals who need to interpret, or wish to perform their own, time trend analyses of BMI.

Introducing excess body weight in childhood and adolescence and comparison with body mass index and waist-to-height ratio

BACKGROUND

Weight status in children and adolescents is commonly defined using age- and gender-corrected standard deviation scores for body mass index (BMI-SDS, also called z-scores). Values are not reliable for the extremely obese however. Moreover, paediatricians and parents may have difficulties understanding z-scores, and while percentiles are easier to gauge, the very obese have values above the 99th percentile, making distinction difficult. The notion of excess body weight (EBW) is increasingly applied in adult patients, mainly in the context of bariatric surgery. However, a clear definition is not available to date for the paediatric population.

METHODS

A simple definition of EBW for children and adolescents is introduced, with median weight as a function of height, age and gender (characterized by an asterisk): EBW (%) = 100x(weight-median weight*)/median weight*. EBW is compared with BMI-SDS and waist-to-height ratio (WHtR). Using two data sources (APV registry and German Health Interview and Examination Survey for Children and Adolescents (KiGGS)) including more than 14,000 children, the relationships between these anthropometric and various metabolic parameters are analysed for a group of overweight/obese children who have sought obesity therapy (APV), for the general paediatric population and for the subset of overweight/obese children from the general population (KiGGS).

RESULTS

The three anthropometric parameters are strongly correlated, with the linear correlation coefficients exceeding 0.8 in the general population and 0.75 in those seeking obesity therapy. Moreover, their relationship to metabolic parameters is quite similar regarding correlations and area under the curve from receiver operating characteristic analyses.

CONCLUSIONS

EBW has similar predictive value for metabolic or cardiovascular comorbidities compared with BMI and WHtR. As it is reliable at the extreme end of the obesity spectrum, easily communicable and simple to use in daily practice, it would make a very useful addition to existing tools for working with obese children and adolescents. Its usefulness in assessing weight change needs to be studied however.