Body Mass Index Reference Curves For Sri Lanka

Body Mass Index reference curves for Sri Lanka
P M G Punchihewa1, L P C Saman Kumara2
Sri Lanka Journal of Child Health, 2001; 30: 98-102
(Key words: Body mass index, reference curves, Sri Lanka)
Abstract BMI as a measure for underweight and over-weight is

used in adults but its use in childhood has developed
Body Mass Index (BMI) or weight/height1,2 has been relatively recently. Adult BMI increases fairly slowly
popular for assessing obesity in adults for many years, with age, so that age independent cut offs can be used to
but its use in children has developed only recently. grade obesity. In children, however BMI changes
B.M.I. is widely accepted, as it provides a convenient substantially with age, rising steeply in infancy falling
measure of obesity, which is less affected by differences during the pre-school years and then rising into
in timing of puberty than weight for height charts. Child adulthood. For this reason childhood BMI needs to be
BMI age reference charts have been published in several assessed using age related reference curves. The aim of
countries and the aim of this paper is to formulate a set this pilot study is to explore the possibility of providing
of curves for Sri Lankan children reference curves for BMI covering the age range of 05-
16 years.
Method
Subjects
1182 school children from year 01 to year 07 from Galle
District were included in this study group. Standing The reference sample of children was obtained from 17
height was measured to the nearest 0.1 cm. Children schools from Galle district. These schools included
were weighed with the least amount of clothes using a National schools as well as others. They were randomly
calibrated mechanical scale. Children with diagnosed selected from a list of schools obtained from The
growth disorders and those on medication known to Ministry of Education of Southern Province. After
interfere with growth were excluded. obtaining prior permission, these schools were visited,
and the students from grade 01 to grade 07 were
Statistical analysis of data obtained, were entered into a randomly selected making use of the attendance register.
computer and analyzed according to a previously Children with diagnosed growth disorders and those on
published programme used, for the derivation of general medication known to interfere with growth were
population centiles. The results have been calculated as excluded. This sample contained a socioeconomic
centiles and as SD scores. mixture of privileged and less privileged families.
Introduction Data
Weight and Height are highly correlated during Trained medical professionals performed measurements.
childhood, so that a child's weight centile tends to be Standing height was measured to the nearest 0.1cm.
strongly influenced by his or her height centile. Both are Children were weighed with minimum amount of
a reflection primarily of the child's size rather than their clothes or the weight was adjusted for clothing weight.
shape. Weight adjusted for height provides a simple Exact date of birth was obtained from the attendance
measure of fatness and many weight-for-height indices register.
have been proposed for this purpose. The American
National Centre for Health Statistics (NCHS) growth Statistical Analysis
reference included weight for height charts. A problem
with these charts is that they fail to adjust for age in BMI was calculated from the weight and height with
early life, when body fat content differs substantially3. A units, kg/m2. The analyses were done for the sexes
very flexible and convenient measure of a person's separately. Since the distribution of BMI in a population
fatness, which removes most of the trend of increasing tends to be positively skewed, the BMI reference
weight with age, is BMI defined as: centiles were derived using the LMS Method4. In brief
this method summarizes the centiles by 03 smooth
Body weight in kg curves representing the distribution of BMI at each age
Square of the height in metres by its median (M curve) and coefficient of variation (S
___________________________________________ curve) plus a measure of skewness (L curve) required to
1
Consultant Paediatrician, 2Paediatric Registrar, transform the data to normality. The M curve is the 50th
Teaching Hospital, Karapitiya. centile curve for BMI.
Results
The data set consists of BMI for 1182 children, out of

whom 756 were females and 426 were males. Age
distribution of the studied population was from 5 to
17 years. The age and sex distribution of the
population is shown in Figure 1.
Figure 3 Comparison of British male and female

median curves
Figure 1 Age and sex distribution
The changes in median BMI by age are on the whole

very similar in the 02 sexes. After the adiposity
rebound (which is the dip in the BMI) the BMI curve
increases more rapidly in girls than in boys. (Figure
2)
Figure 4 Comparison of coefficient of variation of BMI

(S Curve) male and female
Figure 4 shows the S curves (coefficient of variation of

BMI) of boys and girls. The rise in variability occurs
earlier in girls reflecting the timing of the adolescent
growth spurt in the two sexes.
BMI reference centiles for our population of boys and

girls are shown in the seven centile format in Figure 5.
Seven centiles are similar to the conventional 3rd, 10th,
25th, 50th, 75th, 90th and 97th.
Figure 2 Comparison of male and female median
curves
Figure 6 compares our results with British 50th centile
for girls and boys. B.M.I. is consistently higher in the
When compared, our findings are consistent with British population. Their 50th centile for females falls
British data, note the rapid increase of BMI in girls on our 90th centile and that of boy’s falls well above our
after the adiposity rebound; at 18 years the curves 97th centile.
cross to give rise to subsequent higher BMI for
boys.(Figure 3)
Figure 5 BMI reference curves
Figure 6 Comparison with British boys and girls
Discussion This phenomenon explains why our charts show

adiposity rebound as late as 08 years when com-pared to
BMI charts can be used to identify children who are British adiposity rebound of 5.5 years. BMI curves
unusually fat or thin on the basis of a single published in 1995 by the Family Health Bureau in
measurement and provides an index, which is very Collaboration with Medical Research Institute has taken
useful for large-scale epidemiological purposes. It is less 5th and 85th centiles as reference curves. When
affected by differences in timing of puberty than weight comparing, our 5th and the 85th centiles are
for height charts. significantly lower than theirs (Figure 8).
British BMI charts recently published by the Child

Growth Foundation spans from birth to 23 years and the
centiles were fitted using Cole's LMS method, which is
what we used for analysis of our data4. In a
comprehensive review of more than 60,000 healthy
children from the USA, aged 5-17 years, it was shown
that Asian children have the lowest values5. This was
shown to be the case for adult population as well.
Comparison of our results with British BMI is consistent
with these findings and this difference is secondary to
genetic and environmental impacts on growth. It is clear
now that it could create serious anomalies in
classification of growth if we continue to use British
reference curves. As shown on this British chart, BMI
increases steeply in early life, subsequently it declines
and then flattens out. This dip - the adiposity re-bound,
occurs earlier on the higher than the lower centiles with
a difference of up to 3-4 years (Figure 7). Figure 7 British B.M.I. chart demonstrating adiposity
rebound
Figure 8 Comparison of 5th and 85th centiles against MRI data. .
Though the sample size is small we emphasize that the References

urban population we surveyed contains a socioeconomic
mixture representative of the national urban pattern. 1. Prentice A M. Body mass index standards for
children. BMJ 1998; 317: 1401-13.
In conclusion
2. Preece M, Cole T, Fry T. Body mass index
• BMI charts taken in conjunction with those for standards for children. BMJ 319; 122a-122.
height and weight provide a measure for
underweight and overweight. 3. Cole T J. A critique of the NCHS weight for height
• These findings signal the need to have our national standard. Hum Biol 1985; 57: 183-96.
charts for height, weight and BMI.
4. Cole T J. A method for assessing age-standardized
• It is important to update growth curves regularly to weight-for-height in children seen cross-
demonstrate the secular changes sectionally, Ann Hum Biol 1979; 6: 249-68.
Acknowledgements 5. Freeman J V, Cole T J, Chinn S, Jones P R M.

Cross sectional stature and weight reference curves
We are ever so grateful to Prof. Tim Cole, Professor of for the UK, 1990. Arch Dis. Child 1995; 73: 17-24.
Medical Statistics at the Institute of Child Health, UK
for the statistical support and the encouragement given
in preparing this paper. We would also like to thank all
the principals for granting permission, teachers and all
the students who were involved in this study.

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Body Mass Index reference curves for Sri Lanka

P M G Punchihewa1, L P C Saman Kumara2

Sri Lanka Journal of Child Health, 2001; 30: 98-102

(Key words: Body mass index, reference curves, Sri Lanka)

Abstract BMI as a measure for underweight and over-weight is

The data set consists of BMI for 1182 children, out of

Figure 3 Comparison of British male and female

Figure 1 Age and sex distribution

The changes in median BMI by age are on the whole

Figure 4 Comparison of coefficient of variation of BMI

Figure 4 shows the S curves (coefficient of variation of

BMI reference centiles for our population of boys and

Figure 6 Comparison with British boys and girls

Discussion This phenomenon explains why our charts show

British BMI charts recently published by the Child

Though the sample size is small we emphasize that the References

Acknowledgements 5. Freeman J V, Cole T J, Chinn S, Jones P R M.

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