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Use of anthropometry in school-aged children and adolescents

This is a summary of a Field Exchange research summary that was included in issue 66. The original article was authored by Natasha Lelijveld

Natasha Lelijveld is a Senior Nutritionist at ENN.

This article summarises the use of anthropometry to assess nutritional status in school-aged children and adolescents

  • A number of challenges exist including the use of different age categories, reference data and indicators for malnutrition.
  • More data and greater standardisation of anthropometric indicators would support the development of nutrition policies, guidelines and programmes for these age groups.

Being under- or over-nourished during childhood and adolescence is associated with adverse consequences. Across all age groups, anthropometry is used to assess nutritional status and subsequent health risks. However, there is a lack of evidence, clarity and standardisation on assessing and classifying malnutrition in school-aged children and adolescents.

In recent years, the importance of nutrition in school-aged children and adolescents has been recognised. Indicators for anaemia in adolescent girls are included in the Sustainable Development Goals and large global datasets have been utilised to summarise the prevalence of malnutrition in adolescents. Table 1 summarises the papers in which anthropometric data has been most comprehensively reported. These papers have included data for different age ranges and have defined thinness and overweight using different reference data with different cut-off values. This limits our understanding of global and national prevalence rates as well as our ability to compare between settings and understand trends.

Table 1: Summary of references and cut-offs used for school-aged children and adolescents

 

WHO 2007 growth reference

IOTF growth reference

CDC growth reference

WHO adult cut-off

Applicable age bracket

5-19 years

2-18 years

2-18 years

>18 years

Weight categories

Thin or underweight

BAZ <-2

Equivalent to BMI <18.5 at 18 years

BAZ <5th percentile

BMI <18.5

Normal weight

BAZ -2 to +1

Equivalent to BMI 18.5 to <25 at 18 years

BAZ ≥5th percentile to <85th percentile

BMI 18.5 to <25

Overweight

BAZ >+1

Equivalent to BMI ≥25 at 18 years

BAZ ≥85th percentile

BMI ≥25

 

Obesity

BAZ >+2

Equivalent to BMI ≥30 at 18 years

BAZ ≥95th percentile

BMI ≥30

Abbreviations: BMI, body mass index (kg/m2); BAZ, BMI-for-age z-score; CDC, Centers for Disease Control; IOTF, International Obesity Task Force; WHO, World Health Organization.

 

The Benedict et al paper (2018) was the first demographic and health survey (DHS) report to use adolescent-specific definitions of thinness and overweight (based on the World Health Organization (WHO) 2007 reference). Usually, DHS uses adult thresholds to define thinness (body mass index (BMI) <18.5 kg/m2) and overweight (BMI >25 kg/m2) in adolescents 15-19 years of age. This tends to overestimate the prevalence of thinness and underestimate the prevalence of overweight. The WHO recommends defining thinness as BMI-for-age z-score <-2 and overweight as BMI-for-age z-score >+1, based on the WHO 2007 reference. This reference uses primary data from adolescents in the United States of America in the 1970s but is statistically adapted to reflect more international norms. The International Obesity Task Force (IOTF) reference uses data on children from six countries to align the thresholds for thinness and overweight to adult BMI cut-offs. Using the IOTF reference results in a greater prevalence of thinness and a lower prevalence of overweight than the WHO reference. Often IOTF thinness data is presented as “Grade 1 thinness” which is similar to a BMI z-score <-1.

The interchangeable use of the terms thinness and underweight in the literature often makes it unclear whether BMI or weight-for-age are being presented. As discussed in previous research, the different timing of the adolescent growth spurt and the impact of muscle development on the accuracy of references also adds to the complexity of using anthropometry in school-aged children and adolescents.

Overall, the papers highlighted in Table 2 show that for school-aged children and adolescents in low- and middle-income countries (LMICs):

Table 2: Summary of recent papers presenting prevalence rates of global adolescent anthropometric status

Author, date

Data used

Population and date of data

Thinness definition

Overweight definition

Reference used

Akseer et al, 2017

Global Burden of Disease (GBD) 2013 and WHO Data Repository, Global School-based Student Health Survey (GSHS)

10-24 years

186 countries

2009 to 2015

BMI-for-age Z <-2

BMI-for-age Z >+1

Not specified

Azzopardi et al, 2019

GBD

– compiled secondary data

10-24 years

195 countries

2016

Not reported

 

BMI-for-age equivalent to BMI >25 at age 18 years (10-18 years)

BMI ≥ 25 kg/m2 (19-24 years)

IOTF

Benedict et al, 2018

Demographic and health surveys

15-19 years

87 LMICs

2000 to 2017

BMI-for-age Z <-2

BMI-for-age Z >+1

WHO 2007

Caleyachetty et al, 2018

GSHS and Health Behaviour in School-aged Children surveys

12-15 years

57 LMICs

2003 to 2013

BMI-for-age z<-2

BMI-for-age z>+1

WHO 2007

Spinelli et al, 2021

Childhood Obesity Surveillance Initiative

6-10 years

36 European countries

2015 to 2017

BMI-for-age z<-2

BMI-for-age z>+1

WHO 2007

Ng et al, 2014

GBD, 2013

- compiled secondary data

5-19 years

188 countries

1980 to 2013

Not reported

BMI-for-age equivalent to BMI>25 at age 18 years (some self-reported anthropometry included)

IOTF

NCD Risk Factor Collaboration, 2017

Non-communicable Disease Risk Factor Collaboration database and WHO STEPS surveys

5-19 years

200 countries

2016

BMI-for-age z<-2

BMI-for-age z>+1

WHO 2007

The increasing number of studies presenting prevalence data for malnutrition in school-aged children and adolescents is promising. However, differences in the age categories, reference data and the indicators used limit our understanding of their nutritional status. More data and greater standardisation of anthropometric indicators are needed to monitor trends, design solutions and set national and global targets.

For more information, please contact Natasha Lelijveld at natasha@ennonline.net.

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Natasha Lelijveld (). Use of anthropometry in school-aged children and adolescents. FEX 66 Digest , March 2022. www.ennonline.net/fexdigest/66/anthropometricassessment

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