Body mass index (BMI) and waist circumference (WC) correlate with cardiovascular (CV) risk factors in childhood which track into adulthood. WC provides a measure of central obesity, which has been specifically associated with CV risk factors. Reference standards for WC, and for WC and BMI risk threshold values are not established in Chinese children.
To construct reference percentile charts of WC, establish relationships between WC, BMI and other risk factors, and propose WC and BMI threshold values predictive of CV risk factors in Hong Kong ethnic Chinese children.
Weight, height, waist and hip circumference were measured in 2593 (52% boys, 47% girls) randomly sampled Hong Kong school children aged 6–12 years. In 958 of these and 97 additional overweight children (n=1055), the relationships between WC, BMI, waist/hip and waist/height ratio and six age-adjusted CV risk factors (>85% percentile levels of blood pressure (BP), fasting triglycerides, low-density lipoprotein (LDL) cholesterol, glucose and insulin levels, and <15% percentile levels of high-density lipoprotein (HDL) cholesterol) were studied. Receiver-operating characteristic analysis was employed to derive optimal age-adjusted sex-specific WC and BMI thresholds for predicting these measures of risk.
WC percentiles were constructed. WC correlated slightly more than BMI with CV risk factors and most strongly with insulin and systolic BP, but poorly or not with LDL and glucose. Optimal WC and BMI risk thresholds for predicting four of these six CV risk factors were ca. the 85th percentiles (sensitivities ∼0.8, specificities ∼0.87) with age-specific cutoff values in girls/boys from ∼57/58 to ∼71/76 cm and 17/18 to 22/23 kg/m2.
These are the first set of WC reference data for Chinese children. WC risk cutoff values are proposed which, despite a smaller waist in Chinese children, are similar to those reported for American children. WC percentiles may reflect population risk.
Obesity is associated with clustering of cardiovascular (CV) risk factors – insulin resistance, dyslipidaemia and hypertension – empirically recognized as ‘The Metabolic Syndrome’ and with CV outcome.1, 2, 3, 4 Clustering of these CV risk factors in children and adolescents tends to track into adult life.5, 6, 7, 8, 9
CV disease appears to be related specifically to intra-abdominal fat (visceral adipose tissue)10, 11 of which waist circumference (WC) provides a good and clinically useful measure,12, 13, 14, 15, 16, 17 supporting the growing view that WC is a better measure of CV risk than body mass index (BMI) in both children and adults.18, 19, 20, 21
Ethnic differences of WC have been described in adults22, 23 but have not been studied in children, although reference data for WC are available from a number of different countries.24, 25, 26, 27, 28, 29, 30, 31 Data for ethnic Chinese children have not previously been reported.
The purposes of the present study were to develop WC percentiles for ethnic Chinese children; to confirm the relationships between WC, BMI and other CV risk factors in these children; and to develop optimal WC and BMI risk threshold percentiles and cutoff values for this population, to compare with reports in other ethnic groups.
The ‘Population Group’ studied comprised 2593 ethnic Chinese children aged 6–13 years inclusive. They were recruited from 90 classes randomly sampled in eight primary schools participating in University-based health promotion activities in different districts of Hong Kong between 2002 and 2004. Letters sent to all children's parents in randomly selected classes via their school teachers resulted in an 82% positive response. The main reason for non-participation was that not all families could attend the schools as requested 1 hour before normal school opening, whereas a small number refused venepuncture. Responders may be considered to be representative of the population studied.
Written consent for physical examination and blood sampling was obtained from the parents. Information about pubertal status was not sought to avoid prejudicing consent to recruitment. The body weight, height, WC and hip circumference data from these 2593 children (the population group) were used to construct reference WC and BMI percentile charts for this population. Nine hundred and fifty-eight children from this Group were randomly selected to have blood pressure (BP) measured and fasting blood samples taken for lipids, glucose and insulin measurements.
In order to increase the number of overweight children in whom WC and BMI were to be related to CV risk factors, data from 97 additional children (from the same community) who were voluntarily participating in a University-based weight control programme were included – randomly selected and with 100% agreement. These formed the ‘Clinic Group’ and their data were pooled with those of the 958 children from the population group, bringing the number of children in whom CV risk factors were measured to 1055 (the ‘CV Risk Evaluation Group’).
The study protocol was approved by the University ethics committee and informed consents were obtained from all participants and their parents.
Anthropometric and BP measurements
BMI and waist/hip and waist/height ratios were derived from measurement of weight, height and waist and hip circumference. Weight was measured to the nearest 0.1 kg and height to the nearest 0.5 cm, wearing light T-shirt and shorts without shoes. WC was measured midway between the lowest rib and the superior border of the iliac crest. Hip circumference was measured at maximal protrusion of the buttocks. The circumferences are given as the mean of two measurements to the nearest 0.1 cm.
BP was measured by sphygmomanometry to the nearest 2 mm Hg, twice in the right arm, seated, after 10 minutes rest, and a third time if the two readings were >4 mm Hg apart. Diastolic pressure was defined as the point of disappearance of Korotkoff sound (5th phase).
The intra-class (within-observer) correlation coefficients, based on pairs of replicate measurements made by the same observer on the same day, were >0.99 for BMI, 0.97 for WC, 0.94 for systolic BP and 0.95 for diastolic BP.
Blood lipids, glucose and insulin levels
Venous blood samples were taken after 12 h fasting for determination of blood lipids, glucose and insulin concentrations. Plasma lipids were assayed enzymatically using the Boehringer Mannheim Hitachi 911 analyzer. Triglyceride (TG) was measured using the lipase/glycerol kinase method. High-density lipoprotein (HDL) cholesterol was measured after phosphotungstate-magnesium precipitation and low-density lipoprotein (LDL) cholesterol was calculated using the Friedewald equation. The intra-assay coefficients of variation (CVs) were 1.9% for total cholesterol, 1.9% for TG and 5.4% for HDL. Plasma glucose was measured by a glucose oxidase method (Diagnostic Chemicals reagents kit, Diagnostic Chemicals Ltd, Prince Edward Island, Canada). The intra-assay CV of glucose was 2% at 6.6 mmol/l. Serum insulin was determined using radioimmunoassay (Pharmacia Diagnostics Lab, Uppsala, Sweden). The lowest limit of detection was <2 μU/ml.
Age- and sex-specific WC percentiles
Reference sex- and age-specific percentile curves, smoothed by the LMS method,32 were constructed for WC and BMI from the data provided by the population group (n=2593).
CV risk factors
CV risk factors included in this study covered the three main parameters of high BP, dyslipidaemia and insulin resistance. They comprised high (i) BP (systolic and/or diastolic), fasting (ii) LDL cholesterol, (iii) TGs, (iv) glucose, (v) insulin and low (vi) fasting HDL cholesterol – see Statistical analysis for derivation of these risk thresholds. TG and insulin were logarithmically transformed to correct for skewness. Clustering of CV risk factors was empirically defined by the presence of either three-or-more or four-or-more of these six conventional risk factors.
WC and BMI of the 958 children of the population group in whom blood samples were obtained were regressed with respect to age (with up to a cubic polynomial of terms: age, age2 and age3) using stepwise regression procedures to provide gender-specific regression equations. These provided norms which were then applied also to age-adjust the data from the 97 children in the Clinic Group. The actual WC and BMI of each of the 1055 children in the CV risk evaluation group minus the predicted WC and BMI calculated from the gender-specific regression equations were regarded as the age-adjusted value of WC and BMI. Each CV risk factor value was similarly regressed with respect to age in these 958 children to provide age- and gender-specific regression equations. The standardized residuals of all 1055 children were retained to represent age-adjusted values.
The gender-specific 85th percentile (15th percentile for HDL) for each of the age-adjusted CV risk factors of the 958 blood-tested population group was chosen as the threshold level of ‘high CV risk’ for all children.
Receiver-operating characteristic (ROC) analysis was employed to investigate the diagnostic ability of age-adjusted WC and BMI to identify the presence or absence of risk factor clustering in the CV risk evaluation group (n=1055). The area-under-ROC curve (AUC) was used to give a measure of the global performance of using WC and BMI as effective diagnostic indicators. The value (age-adjusted WC and BMI) corresponding to the nearest point of the ROC curve to the top left-hand corner was chosen as the optimal threshold for predicting clustering of CV risk factors in that it maximizes both sensitivity and specificity (given equal weighting). Sex- and age-specific WC and BMI cutoffs were read from the corresponding percentiles generated using LMS method from the population group (n=2593).22
The relationships between the anthropometric and the CV risk factors in the CV risk evaluation group were examined by age-adjusted partial correlation analysis.
Statistical analyses were performed with SPSS 13.0 (SPSS Inc., Chicago, IL, USA) and LMS programme Version 1.16 (Tim Cole and Huiqi Pan, Institute of Child Health). Data were presented as mean (s.d.). All statistical tests were two-sided and P-value <0.05 was considered statistically significant.
Additional analyses of the data
In view of uncertainties about the nature and definition of the ‘Metabolic Syndrome’ and the differing groupings of risk factors used in different studies, the WC data from the present study were also analysed using (i) the four factors used in the ATP III report (BP, HDL, TG and glucose),33 and (ii) the four factors found to be most strongly associated with WC in the present study.
In addition, for comparison with the closely comparable US Bogalusa study,34 the present data were re-evaluated using the outer quintile (20%) of risk factor percentiles instead of the outer 15%.
The descriptive characteristics of the population group (n=2593, 47% girls, 53% boys) are shown in Table 1. 10.8% of girls and 13.1% of boys were obese (BMI>95th percentile of the Hong Kong Standards).35 Smoothed WC percentile curves are presented in Figure 1.
Pearson's correlation coefficients of the six age-adjusted CV risk factors with the four age-adjusted anthropometric measures are shown in Table 2. All the CV risk factors correlated significantly both with WC and with BMI, except LDL cholesterol in girls and blood glucose in boys. Fasting insulin level was the CV risk factor which correlated most strongly with both WC and BMI, followed by systolic pressure, HDL cholesterol (negative), TG and diastolic pressure, in both girls and boys. Correlations with waist/hip and waist/height ratios were weaker.
The percentages of children classified as having three-or-more and four-or-more of the six CV risk factors were ca. 10% and ca. 3%, respectively. ROC analysis showed that the findings with WC were generally similar to those with BMI (Table 3), although gender- and age-specific ROC curves suggest a slightly greater AUC for WC than BMI (Figure 2).
Risk threshold percentiles for WC were 12 and 15 percentiles higher using four than using three of the six risk factors, with consequently fewer children ‘at risk’. Calculated AUCs (reflecting the optimal composite of sensitivity and specificity) were 0.16 (22%) and 0.05 (6%) greater and risk cutoff WC values averaged 5% (2–4 cm) and 7% (3–5 cm) higher with four than with three of the six risk factors (Table 4). Similar results were obtained with BMI – risk threshold percentiles were 9 percentiles and 16 percentiles higher, AUCs were 0.14 (18%) and 0.05 (6%) greater, and risk cutoff values averaged 6% (4–7 kg/m2) and 9% (7–11 kg/m2) higher with four than with three of the six risk factors.
Analyses of the present data using (i) the four risk factors identified in the ATP III report and (ii) the four CV risk factors most strongly associated with WC – fasting insulin, systolic BP, HDL and TGs are shown in Table 5. Compared with the use of the six risk factors or the four ATP III CV risk factors, the use of the selected four risk factors showed a larger AUC relative to the number of risk factors considered and the number of children at risk. Among the children with three-or-more of the six risk factors, the use of systolic pressure was compared with the use of diastolic BP and shown to give a consistently greater sensitivity (mean of all children: 0.73 cf. 0.69), selectivity (0.80 cf. 0.75) and AUC (0.82 cf. 0.78), supporting a greater contribution of systolic than diastolic BP to the association with WC.
The results of analysing the present data using three-or-more of the six risk factors and the outer quintile (20%) of risk factor percentiles are shown for comparison with the Bogalusa data in Table 5.
This study presents smoothed reference percentile charts for WC and BMI for ethnic Chinese children aged 6–12 years, inclusive. The 11–13% proportion of obesity in the random population group of 2593 children is similar to that reported annually for primary school children in the Territory by the Hong Kong Department of Health (SHS communication, 2002–2003). BMI percentiles are higher than in the first population data for Chinese children's BMI collected in 1993.35 These are the first WC percentile charts for Chinese children to have been reported.
Overall, CV risk may be characterized in terms of the CV risk factors present, although their relative contributions and whether there is synergy between the individual factors underlying the concept of the Metabolic Syndrome have been questioned, as have the diagnostic criteria.36, 37 High WC and BMI levels were confirmed in the present study as being associated with clusters of three-or-more or four-or-more of the six CV risk factors measured. The most strongly associated individual factor of the six was fasting insulin, followed by TG and HDL, with systolic more strongly associated than diastolic BP, and LDL cholesterol and blood glucose only weakly or insignificantly associated – a hierarchy of individual associations similar to that noted previously.38
WC showed a slightly stronger association than BMI with the lipid and insulin risk factors, supporting the growing use of WC in preference to BMI39, 40 and consistent with the fact that WC is a measure of central obesity which is specifically related to the presence of CV risk factors.41, 42 Weight/hip ratio and weight/height ratios, as previously used in adults43, 44 albeit controversially in children,15, 21, 45, 46 were shown to be less strongly associated with the CV risk factors.
Age- and sex-specific optimal threshold levels of WC and BMI for predicting CV risk factors were derived by ROC. Predictably, fewer children had four-or-more than three-or-more of the six risk factors, with higher risk threshold percentiles and greater sensitivity, specificity and AUC. Results with BMI were similar.
In view of unresolved differences in the definition of the Metabolic Syndrome and its diagnostic components, its underlying cause and whether combinations of risk factors are more predictive of CV outcome than the sum of individual risk factors,36 the data were also analysed using two alternative combinations of risk factors used by others, the better to compare findings – (i) using the four risk factors identified in the ATP III report and (ii) using the four risk factors shown in this study to be those most strongly associated with WC which were also those originally considered to be the main features of the Metabolic Syndrome. Differences were small but suggest greater sensitivity and specificity relative to the number of risk factors used with the latter than were found using either the six risk factors or the four ATP III risk factors. Inclusion of LDL and of glucose contributed little to their selectivity. Both correlation coefficients and ROC analysis showed a greater contribution of systolic than diastolic BP, supporting the relative value of systolic pressure in characterizing the Metabolic Syndrome. Nevertheless, the cutoff levels were similar, suggesting that the choice of risk factors does not greatly affect the cutoff levels derived.
Comparable data for percentiles in children from different countries and ethnic groups are limited, but there appear to be differences in WC percentiles between different populations and ethnic groups. In particular the representative 50th percentile for WC (which reflects waist size in the population) was higher in the USA national data collected from 1988 to 199429 than in these ethnic Chinese children in Hong Kong (Figure 3). Data relating WC to CV risk factors in different child populations are scant15, 34, 38, 39, 47, 48 and valid comparisons are limited by differences in methodology (non-random population sampling, different sites of WC measurement, selection and number of CV risk factors) and/or failure to include more than one of the inter-related variables (WC percentiles, WC risk threshold percentiles and cutoff values) in the same study. The only methodologically comparable study to derive WC risk thresholds percentiles and gender- and age-related cutoff values is the Bogalusa study of 2597 Black and White American children,34 in which three-or-more of the same six CV risk factors as in the present study were used. Data from the present study, re-analysed using outer quintiles to define individual risk factors as in the Bogalusa study (instead of the outer 15% in the initial analysis of the present study), showed that WC risk thresholds (which were at the 69th and 66th percentile in girls and boys, respectively) were ∼15% higher than in either the White or the Black American children (Table 5), whereas WC risk cutoff values differed little (Figure 4), consistent with the smaller WC percentiles in ethnic Chinese children than in White and Black Americans. AUCs, sensitivities and specificities were similar in the two studies. This suggests that the relation between central abdominal fat and risk factors may not differ fundamentally between different ethnic and racial populations despite population differences in WC percentiles, supporting the possibility that an international standard for children's WC as a predictive measure of CV risk factors might be feasible. Further closely comparable studies will be needed to establish the extent to which this might be the case.
In summary, this study provides the first percentile charts for ethnic Chinese children's WC. For initial clinical screening, we suggest that optimal thresholds based on the presence of four-or-more of the six risk factors have the advantage over three of six factors of high sensitivity and specificity, and also of higher WC values, which will reduce the number of children who will require weight management. Further analysis of the present study suggests, however, that selective use of the four risk factors originally considered central to the Metabolic Syndrome may provide a more focused approach. Contrary to expectations, standardized risk threshold cutoff values for WC may differ little between different ethnic groups despite anthropometric differences reflected in population WC percentiles. WC percentiles may serve as epidemiological markers of population risk, although this remains to be established.
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This study was supported by the Jump Rope for heart project, Hong Kong College of Cardiology and Polar Electro Oy. We are grateful to Professor AH Henderson, Emeritus Professor of Cardiology and Professor RR West, Department of Statistics and Epidemiology, at the University of Wales College of Medicine, for their critical review of the manuscript. Special thanks go to Professor Tony Nelson for his valuable comments.
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Sung, R., Yu, C., Choi, K. et al. Waist circumference and body mass index in Chinese children: cutoff values for predicting cardiovascular risk factors. Int J Obes 31, 550–558 (2007) doi:10.1038/sj.ijo.0803452
- waist circumference
- cardiovascular risk factors
- Hong Kong
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